Chapter 17 High-Risk Neonatal Nursing Care

Chapter 17  High-Risk Neonatal Nursing Care

Complete Chapter Questions And Answers
 

Sample Questions

Multiple Choice

1. A neonate is born at 33 weeks’ gestation with a birth weight of 2400 grams. This neonate would be classified as: a. Low birth weightb. Very low birth weightc. Extremely low birth weightd. Very premature

ANS: a

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a.
Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight.
b.
Neonates with birth weight less than 1500 grams but greater than 1000 grams are classified as very low birth weight.
c.
Neonates with birth weight less than 1000 grams are classified as extremely low birth weight.
d.
Neonates born less than 32 weeks’ gestation are classified as very premature.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

2. A nurse assesses that a 3-day-old neonate who was born at 34 weeks’ gestation has abdominal distention and vomiting. These assessment findings are most likely related to:a. Respiratory Distress Syndrome (RDS)b. Bronchopulmonary Dysplasia (BPD)c. Periventricular Hemorrhage (PVH)d. Necrotizing Enterocolitis (NEC)

ANS: d

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a.
Assessment findings for RDS include tachypnea, intercostal retractions, respiratory grunting, and nasal flaring.
b.
Assessment findings for BPD include chest retractions; audible wheezing, rales, and rhonchi; hypoxia; and bronchospasm.
c.
Assessment findings for PVH include bradycardia, hypotonia, full and/or tense anterior fontanel, and hyperglycemia.
d.
Assessment findings related to NEC include abdominal distention, bloody stools, abdominal distention, vomiting, and increased gastric residual. These signs and symptoms are related to the premature neonate’s inability to fully digest stomach contents and limitation in absorptive function.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

3. A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions?a. Phototherapyb. Feeding neonate every 2 to 3 hoursc. Switch from breastfeeding to bottle feeding
d. Assess red blood cell count

ANS: b

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a.
Phototherapy is considered when the levels are 12 mg/dL or higher when the neonate is 25 to 48 hours old. Neonates re-absorb increased amounts of unconjugated bilirubin in the intestines due to lack of intestinal bacteria and decreased gastrointestinal motility.
b.
Adequate hydration promotes excretion of bilirubin in the urine.
c.
Colostrum acts as a laxative and assists in the passage of meconium.
d.
Assessing RBC is not a treatment for hyperbilirubinemia.
KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Application | Content Area: Maternity | Client Need: Physiological Adaptation | Difficulty Level: Moderate

4. A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is:a. “Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?”b. “The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?”c. “Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby’s health?”d. “I see that this is very upsetting for you. I will come back later and answer your questions.”

ANS: c

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a.
Correct information, but does not fully address the woman’s concern.
b.
Correct, but GBS is not a sexually transmitted disease.
c.
Correct. This response answers her questions and allows her to ask additional questions about her baby’s health.
d.
Acknowledges that she is upset but does not provide immediate information.
KEY: Integrated Process: Communication and Documentation | Cognitive Level: Comprehension | Content Area: Maternity | Client Need: Psychosocial Integrity | Difficulty Level: Difficult

5. A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following?a. Hypoglycemiab. Hypercalcemiac. Cold stressd. Neonatal withdrawal

ANS: d

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a.
Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability, apnea, lethargy, and temperature instability, but not nasal congestion.
b.
Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac arrhythmias.
c.
Signs and symptoms of cold stress are decreased temperature, cool skin, lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting.
d.
These are common signs and symptoms of neonatal withdrawal.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area: Maternity | Client Need: Physiological Integrity; Physiological Adaptation | Difficulty Level: Moderate