Chapter 36

Question 1

1. To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What is the most common cause of pathologic hyperbilirubinemia?
   a. Hepatic disease
   b. Hemolytic disorders
   c. Postmaturity
   d. Congenital heart defect

Answer 1

ANS: B
Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes.

Question 2

2. Which infant is most likely to express Rh incompatibility?
   a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
   b. Infant who is Rh negative and a mother who is Rh negative
   c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor
   d. Infant who is Rh positive and a mother who is Rh positive

Answer 2

ANS: A
If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive.

Question 3

3. What is the highest priority nursing intervention for an infant born with myelomeningocele?
   a. Protect the sac from injury.
   b. Prepare the parents for the child’s paralysis from the waist down.
   c. Prepare the parents for closure of the sac when the child is approximately 2 years of age.
   d. Assess for cyanosis.

Answer 3

ANS: A
A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) infection. The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

Question 4

4. Which nursing diagnosis is most appropriate for a newborn diagnosed with a diaphragmatic hernia?
   a. Risk for impaired parent-infant attachment
   b. Imbalanced nutrition, related to less than body requirements
   c. Risk for infection
   d. Impaired gas exchange

Answer 4

ANS: D
Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although imbalanced nutrition, related to less than body requirements, may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need; however, at this time the nurse should be most concerned about impaired gas exchange. This infant is at risk for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

Question 5

5. What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis?
   a. Edema
   b. Immature red blood cells
   c. Enlargement of the heart
   d. Ascites

Answer 5

ANS: B
Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema occurs with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces, as well as demonstrate signs of ascites.

Question 6

6. Which statement regarding congenital anomalies of the cardiovascular and respiratory systems is correct?
   a. Cardiac disease may demonstrate signs and symptoms of respiratory illness.
   b. Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress.
   c. Choanal atresia can be corrected with the use of a suction catheter to remove the blockage.
   d. Congenital diaphragmatic hernias are diagnosed and treated after birth.

Answer 6

ANS: A
The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

Question 7

7. When attempting to screen and educate parents regarding the treatment of developmental dysplasia of the hip (DDH), which intervention should the nurse perform?
   a. Be able to perform the Ortolani and Barlow tests.
   b. Teach double or triple diapering for added support.
   c. Explain to the parents the need for serial casting.
   d. Carefully monitor infants for DDH at follow-up visits.

Answer 7

ANS: D
Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is recommended for clubfoot, not DDH.

Question 8

8. The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom indicates that the infant may be displaying the initial phase of encephalopathy?
   a. High-pitched cry
   b. Severe muscle spasms (opisthotonos)
   c. Fever and seizures
   d. Hypotonia, lethargy, and poor suck

Answer 8

ANS: D
The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

Question 9

9. Most congenital anomalies of the CNS result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process?
   a. Maternal diabetes
   b. Maternal folic acid deficiency
   c. Socioeconomic status
   d. Maternal use of anticonvulsant

Answer 9

ANS: B
All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

Question 10

10. The condition, hypospadias, encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn?
    a. Mild cases involve a single surgical procedure.
    b. Infant should be circumcised.
    c. Repair is performed as soon as possible after birth.
    d. No correlation exists between hypospadia and testicular cancer.

Answer 10

ANS: A
Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation.

Question 11

11. The nurse is instructing a family how to care for their infant in a Pavlik harness to treat DDH. What information should be included in the teaching?
    a. Apply lotion or powder to minimize skin irritation.
    b. Remove the harness several times a day to prevent contractures.
    c. Return to the clinic every 1 to 2 weeks.
    d. Place a diaper over the harness, preferably using an absorbent disposable diaper.

Answer 11

ANS: C
Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

Question 12

12. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond?
    a. Traction is tried first.
    b. Surgical intervention is needed.
    c. Frequent, serial casting is tried first.
    d. Children outgrow this condition when they learn to walk.

Answer 12

ANS: C
Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention.

Question 13

13. Which statement regarding hemolytic diseases of the newborn is most accurate?
    a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother.
    b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.
    c. Exchange transfusions are frequently required in the treatment of hemolytic disorders.
    d. The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth.

Answer 13

ANS: D
An indirect Coombs’ test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

Question 14

1. Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from the failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Which factors are included? (Select all that apply.)
   a. Alcohol consumption
   b. Female gender
   c. Use of some anticonvulsant medications
   d. Maternal cigarette smoking
   e. Antibiotic use in pregnancy

Answer 14

ANS: A, C, D
Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate.

Question 15

2. The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions are considered metabolic disorders? (Select all that apply.)
   a. Phenylketonuria (PKU)
   b. Galactosemia
   c. Hemoglobinopathy
   d. Cytomegalovirus (CMV)
   e. Rubella

Answer 15

ANS: A, B, C
PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus.

Question 16

3. The nurse is caring for an infant with DDH. Which clinical manifestations should the nurse expect to observe? (Select all that apply.)
   a. Positive Ortolani click
   b. Unequal gluteal folds
   c. Negative Babinski sign
   d. Trendelenburg sign
   e. Telescoping of the affected limb

Answer 16

ANS: A, B
A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH.

Question 17

Which finding supports the diagnosis of pathologic jaundice?

a. Serum bilirubin concentrations greater than 2 mg/dL in cord blood
b. Serum bilirubin levels increasing more than 1 mg/dL in 24 hours
c. Serum bilirubin levels greater than 10 mg/dL in a full-term newborn
d. Clinical jaundice evident within 24 hours of birth

Answer 17

Ans: D
Clinical jaundice evident within 24 hours of birth supports a diagnosis of pathologic jaundice. This diagnosis is also supported by serum bilirubin concentrations greater than 4 mg/dL in cord blood; total serum bilirubin levels that increase by more than 5 mg/dL in 24 hours; and a serum bilirubin level in a preterm newborn that exceeds 10 mg/dL.

Question 18

With regard to hemolytic diseases of the newborn, nurses should be aware that:

a. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother.
b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.
c. Exchange transfusions are frequently required in the treatment of hemolytic disorders.
d. The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.

Answer 18

Ans: D
An indirect Coombs test may be performed on the mother a few times during pregnancy. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

Question 19

Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is:

a. Tetralogy of Fallot.
b. Ventricular septal defect (VSD).
c. Pulmonary stenosis.
d. Transposition of the great vessels.

Answer 19

Ans: B
VSD with increased pulmonary blood flow is the most common type of heart defect, with a prevalence of 27 per 10,000 births, and accounts for about 30% to 35% of all congenital heart defects. Tetralogy of Fallot has an incidence of 4.7 per 10,000 births and is the most common cardiac defect with decreased blood flow. Pulmonary stenosis, a defect that causes obstruction to blood flow out of the heart, is less common. Transposition of the great vessels is a complex cardiac anomaly that involves a flow of mixed saturated and desaturated blood in the heart or great vessels.

Question 20

Concerning congenital abnormalities involving the central nervous system, nurses should be aware that:

a. Although the death rate from most congenital anomalies has decreased over the past several decades, that from neural tube defects (NTDs) has gone up in the last few years.
b. Spina bifida cystica usually is asymptomatic and may not be diagnosed unless associated problems are present.
c. A major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury.
d. Microcephaly can be corrected with timely surgery.

Answer 20

Ans: C
The nurse protects the infant by laying the baby on his or her side. Most congenital anomalies have had a stable neonatal death rate since the 1930s; rates of NTDs are declining because of mandatory fortification of foods with folic acid. Spina bifida occulta often is asymptomatic; spina bifida cystica has a visible sac. Microcephaly is a tiny head; there is no treatment.

Question 21

Which statement is accurate regarding the ABO blood typing system in the body?

a. If you have type O blood, then you have antigens.
b. If you have type AB blood, then you have antibodies.
c. A person with type O blood has no antibodies.
d. A person with type O blood has antibodies to type A and type B.

Answer 21

Ans: D
A person with type O blood has antibodies to both type A and type B, but no antigens. With type AB blood, you do not have antibodies.

Question 22

An Rh-negative woman has a miscarriage during the 8th week of pregnancy and a D&C is required. Which priority intervention would be required in the recovery period following the surgical procedure?

a. Type and screen for two units of blood.
b. Maintain hydration level by increasing fluids by mouth.
c. Administer RhoGAM.
d. Perform fundal massage.

Answer 22

Ans: C
Administering RhoGAM would be a priority intervention because the patient is Rh negative and there is no way to determine the Rh status of the fetus. Type and screen would not be indicated as if the patient were to require a blood transfusion; this would not reflect holding blood. Although it would be important to maintain the patient’s hydration level, it could be done if needed via the parenteral route. Fundal massage would not be indicated at 8 weeks of gestation.

Question 23

A nurse is working in the nursery and observes a nursing student repeatedly performing an Ortolani test. What priority action should the nurse take?

a. Help the nursing student with performing the test to make sure that it is being done accurately.
b. Document the findings of the test as performed by the nursing student after the test has been repeated three times.
c. Have the nursing student explain what the test is used for in terms of clinical assessment.
d. Have the student stop performing the test immediately.

Answer 23

Ans: D
The Ortolani test should be performed by an experienced practitioner so as to avoid any possible damage. It should not be performed repetitively. Although it would be important to ascertain whether the nursing student knew the clinical implication for the test, the priority safety action would be to intervene and stop further testing.

Question 24

A nurse is performing an assessment on a newborn and notes 6 digits on each foot. This finding is an example of:

a. Congenital hip dysplasia.
b. Hypospadias.
c. Polydactyly.
d. Clubfoot.

Answer 24

Ans: C
Polydactyly is a congenital deformity associated with extra digits. Congenital hip dysplasia indicates a dislocated hip. Hypospadias indicates an abnormality of the external genitalia. Clubfoot can be positional or congenital in nature and is a foot deformity.

Question 25

A nurse is performing a pulse oximetry reading on a newborn to test for:

a. PKU.
b. Congenital heart disease.
c. Sickle cell disease.
d. Thalassemia.

Answer 25

Ans: B
Pulse oximetry can be used to determine the presence of congenital heart disease in healthy newborns. Routine screening of newborns is done via the Guthrie heelstick test to look for certain metabolic diseases such as PKU, sickle cell disease, and thalassemia.

Question 26

In terms of Rh incompatibility, which situations would cause a potential problem? Select all that apply:

a. Rh-negative mom having an Rh-positive baby
b. Rh-negative mom having an Rh-negative baby
c. The infant of an Rh-negative mom with Rh-positive father who is homozygous for the trait
d. Rh-positive baby born to an Rh-positive mom

Answer 26

Ans: A, C
An Rh-negative mom having an Rh-positive baby is the classic presentation for isoimmunization or Rh incompatibility. The infant of an Rh-negative mom with an Rh positive father who is homozygous for the trait would have a potential problem because the infant would be Rh-positive. The other two situations would not cause a problem.