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Flashcards in Chapter 9 Deck (11):
1

Which is an appropriate nursing intervention when caring for an infant with narcotic abstinence syndrome (NAS)?
a. Wrap the infant snugly.
b. Initiate an early stimulation program.
c. Place the infant in an infant seat for feedings.
d. Teach the mother how to provide tactile stimulation.

Ans: A
Infants with narcotic abstinence syndrome who are irritable respond to physical comforting and close contact. Wrapping the infant snugly minimizes self-stimulation, thereby decreasing stimulation.
Infants with narcotic abstinence syndrome require less stimulation.
It is suggested that infants with narcotic abstinence syndrome be breastfed if the mother is negative for human immunodeficiency virus (HIV) and is not using illicit substances; therefore, feeding in an infant seat may be inappropriate.
Infants with narcotic abstinence syndrome require less stimulation; therefore, the mother should be taught to limit tactile stimulation, not increase it.

2

The nurse receives a report about a newborn stating that the mother has type O+ blood and the infant has type B+ blood. The infant is at highest risk for developing
a. Hyperbilirubinemia
b. Hypoglycemia
c. Erythema toxicum
d. Phenylketonuria

Ans: A
There is an ABO incompatibility between the mother and the newborn. This puts the infant at increased risk for hyperbilirubinemia.
Hypoglycemia, in which serum glucose levels are low, may appear a short time after birth. It often occurs in infants of diabetic mothers.
Erythema toxicum is a newborn rash of small, yellow-to-white colored papules surrounded by red skin.
Phenylketonuria is an inborn error of metabolism caused by a deficiency of the enzyme needed to metabolize the essential amino acid phenylalanine.

3

The nurse receives a report about a newborn who was resuscitated at birth secondary to poor respiratory effort. Which assessment data would concern the nurse 6 hours after birth?
a. Sleepiness during feeding
b. Acrocyanotic hands and feet
c. Low body temperature
d. Respirations of 40 breaths per minute

Ans: C
An infant with respiratory difficulty at birth requires frequent and further assessment. Any time an infant has a low body temperature with difficulty stabilizing the temperature, the infant is at increased risk for further respiratory complications.
Many newborns are sleepy during initial feedings following birth.
Acrocyanotic hands and feet is a normal finding in newborn infants.
The normal respiratory rate for newborns is 30 to 60 breaths per minute.

4

A newborn is delivered at 33 weeks’ gestation and is admitted to the special care nursery after administration of exogenous surfactant in the delivery room. The diagnosis associated with the use of surfactant is
a. Meconium aspiration syndrome
b. Apnea of prematurity
c. Persistent pulmonary hypertension
d. Respiratory distress syndrome

Ans: D
Respiratory distress syndrome (RDS) is a respiratory disorder often associated with premature development of the lungs and lack of natural surfactant secondary to prematurity. Surfactant is administered as the treatment for RDS.
Meconium aspiration syndrome is not associated with surfactant.
Apnea of prematurity is not associated with the use of surfactant.
Persistent pulmonary hypertension is not associated with the use of surfactant.

5

The nurse in the delivery room should anticipate that which of the following measures will be taken first for an infant delivered with meconium-stained fluid?
a. Bag-and-mask ventilations
b. Immediate intubation after delivery
c. Oxygen applied by mask
d. Use of a bulb syringe to suction the mouth and nose before the shoulders are delivered

Ans: D
Using a bulb syringe to suction the mouth and nose before the shoulders are delivered will prevent the possibility of aspiration of meconium into the lungs once the first breath is taken. The other measures may be performed after this initial step as needed.
Bag-and-mask ventilations are not administered unless needed.
Immediate intubation after delivery is not performed unless needed.
Oxygen applied by mask is not performed unless needed.

6

The nurse is assessing newborns during a routine shift assessment. Which infant requires further assessment?
a. Heart rate of 120 beats per minute; respiratory rate of 45 breaths per minute
b. Heart rate of 135 beats per minute; respiratory rate of 65 breaths per minute
c. Heart rate of 150 beats per minute; respiratory rate of 35 breaths per minute
d. Heart rate of 145 beats per minute; respiratory rate of 55 breaths per minute

Ans: B
The expected heart rate for a newborn is 110 to 160 beats per minute, and the expected respiratory rate is 30 to 60 breaths per minute. Any vital signs noted outside the expected range require further assessment.
A heart rate of 120 beats per minute and a respiratory rate of 45 breaths per minute are within the normal range.
A heart rate of 150 beats per minute and a respiratory rate of 35 breaths per minute are within the normal range.
A heart rate of 145 beats per minute and a respiratory rate of 55 breaths per minute are within the normal range.

7

A 1-day-old breastfed neonate, with the same blood type and Rh type as its mother, has a yellowish facial tone and a bilirubin level of 9.0. The most appropriate response by the nurse is
a.“Infants’ livers can’t produce enough glycogen to bind to the circulating bilirubin.”
b. “Your baby is breaking down fetal red blood cells, and bilirubin is a waste product.”
c. “Your baby probably has breast milk jaundice, which is common for a 2-day-old infant.”
d. “We should restrict fluids until the baby can clear the bilirubin from its system.”

Ans: B
Bilirubin is one of the breakdown products of hemoglobin that results from red blood cell destruction. The baby’s red blood cells are destroyed and the liver is too immature to maintain a balance between the destruction and excretion. The result is elevated bilirubin levels and a yellow hue to the skin tone of the baby.
Infants’ livers can’t produce enough glycogen to bind to the circulating bilirubin is not a correct statement.
Breast milk jaundice is common for 2- to 4-day-old infants.
Restricting fluid will make the problem worse. Early frequent breastfeeding promotes increased intestinal motility, decreasing enterohepatic shunting and establishing normal bacterial flora in the bowel to effectively enhance the excretion of unconjugated bilirubin.

8

The nurse is gavage feeding a preterm neonate. Which nursing intervention should be introduced prior to and during the gavage feeding?
a. Position the neonate on the abdomen between feedings
b. Provide blow-by oxygen prior to feedings
c. Warm the gavage tube prior to insertion
d. Provide a pacifier during feedings

Ans: D
Providing a pacifier directly before and during the feedings is considered nonnutritive sucking and may help prepare the infant for feeding. It may also improve weight gain, improve milk intake, and possibly increase full oral feedings.
Position the infant on the right side.
Oxygen is not generally needed during gavage feeding.
There is no need to warm the tube prior to insertion.

9

An infant at 36 weeks’ gestation with a maternal history of gestational diabetes is moved to the NICU from the transitional nursery at 3 hours of life. The infant is noted to have poor muscle tone and rapid respirations with retractions. The most probable diagnosis for this infant is
a. Hyperbilirubinemia
b. Respiratory distress syndrome
c. Acrocyanosis
d. Polycythemia

Ans: B
The infant is most likely to have respiratory distress syndrome (RDS). RDS is often associated with preterm delivery and also with mothers who have gestational diabetes. The infant needs further assessment and support in the NICU.
Hyperbilirubinemia is indicated by jaundice.
Acrocyanosis is a persistent blue or cyanotic discoloration of the extremities.
In polycythemia, the proportion of blood volume that is occupied by red blood cells increases.

10

Phenylketonuria (PKU) testing is most accurate when obtained
a. 20 hours after birth.
b. 24 to 48 hours after birth.
c. during newborn transition.
d. at the newborns two-week check-up.

Ans: B
At 24 to 48 hours after birth test results for PKU will be reliable because the newborn has ingested an ample amount of the amino acid phenylalanine, which is a constituent of human milk.
PKU is an inborn error of metabolism and testing is not reliable until the newborn has ingested an ample amount of the amino acid phenylalanine, which is a constituent of human milk.
PKU is an inborn error of metabolism and is not reliable until the newborn has ingested an ample amount of the amino acid phenylalanine, which is a constituent of human milk.
PKU is an inborn error of metabolism and testing is not reliable until the newborn has ingested an ample amount of the amino acid phenylalanine, which is a constituent of human milk.

11

A newborn has antibiotics ordered for possible sepsis. Which nursing intervention would the nurse prepare to implement? (Select all that apply)
a. obtain blood cultures
b. restrict parental visits.
c. monitor temperature.
d. monitor oxygen levels.
e. monitor blood sugars for signs of hypoglycemia.

Ans: A, C, D, E