Chapter 28
1) The nurse is caring for pregnant patients. Which of these clients should the nurse anticipate
is most likely to have a newborn at risk for mortality or morbidity?
1. 37-year-old G8 P2323, works in a chemical factory
2. 23-year-old primip, low socioeconomic status, unmarried
3. 16-year-old primip, began prenatal care at 30 weeks
4. 28-year-old G2 P1001, history of gestational diabetes
Answer: 1
Rationale 1:
This patient is at greatest risk because she has multiple risk factors: age over 35, high parity,
history of preterm birth, and exposure to chemicals that might be toxic.
Rationale 2:
The main risk factor for this patient is her low socioeconomic status.
Rationale 3:
This patient has two risk factors: young age and late onset of prenatal care.
Rationale 4:
This patient has gestational diabetes history as her only risk factor.
2) Small-for-gestational-age infants often have complications at birth, but they may also
experience long-term complications. The long-term effect that is most likely to occur in SGA
infants is:
1. Change from thin and underweight as a child to overweight or obese as adolescents
2. Poor fine motor coordination
3. Paralysis below the hips
4. Permanent disfiguration
Answer:
Rationale 1:
This long-term effect is often seen in children with fetal alcohol syndrome, not SGA.
Rationale 2:
SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination,
hyperactivity, learning disabilities, and hearing loss.
Rationale 3:
Many infants with myelomeningocele will suffer life-long paralysis below the site of the cyst.
Paralysis is not generally associated with SGA infants.
Rationale 4:
Although it may occur, disfiguration is not commonly associated with SGA infants. Instead,
disfiguration is more likely to remain in infants with congenital anomalies such as cleft
lip/cleft palate, even after corrective surgery.
3) A 38-week newborn is found to be small for gestational age. Which of the following
nursing interventions should be included in the care of this newborn?
1. Monitor for feeding difficulties.
2. Assess for facial paralysis.
3. Monitor for signs of hyperglycemia.
4. Maintain a warm environment.
Answer: 4
Rationale 1:
LGA newborns are more difficult to arouse to a quiet alert state and can have feeding
difficulties.
Rationale 2:
LGA newborns often are prone to birth trauma, such as facial paralysis, due to cephalopelvic
disproportion.
Rationale 3:
SGA newborns are more prone to hypoglycemia.
Rationale 4:
Hypothermia is a common complication of the SGA newborn; therefore, the newborn’s
environment must remain warm to decrease heat loss.
4) A 7 pound, 14 ounce girl was born to an insulin-dependent type 2 diabetic mother two
hours ago. The infant’s blood sugar is 45mg/dl. The best nursing action is:
1. Recheck the blood sugar in four hours.
2. Begin an IV of 10% dextrose.
3. Feed the baby one ounce of formula.
4. Document the findings in the chart.
Answer: 4
Rationale 1:
Infants of diabetic mothers should be fed frequently and should have their blood sugar
assessed frequently. Four hours is too long a time frame.
Rationale 2:
45mg/dl is considered a normal blood sugar reading for a neonate. No IV is needed.
Rationale 3:
Feeding would be appropriate if the infant’s blood sugar was below 40, but this infant’s
reading is 45 mg/dl.
Rationale 4:
A blood sugar of 45 mg/dl is a normal finding; documentation is an appropriate action.
5) An infant was born at 31-weeks’ gestation and weighed 1430 g. What is the correct initial
feeding regimen for this infant?
1. 10 mg/kg/day of premature formula 24 kcal/oz.
2. 20 mg/kg/day of premature formula 24 kcal/oz.
3. 40 mg/kg/day of postdischarge formula 22 kcal/oz.
4. 50 mg/kg/day of term formula 20 kcal/oz.
Answer: 2
Rationale 1:
This is the correct initial feeding regimen for preterm infants with a birth weight under 1250
g.
Rationale 2:
This is the correct initial feeding regimen for preterm infants with a birth weight between
1251 and 1500 g.
Rationale 3:
This is the correct initial feeding regimen for preterm infants with a birth weight between
1801 and 2500 g.
Rationale 4:
This is the correct initial feeding regimen for preterm infants with a birth weight over 2500 g.
6) The pregnant patient at 41 weeks is scheduled for labor induction. She asks the nurse if
induction is really necessary. What response by the nurse is best?
1. “Babies can develop postmaturity syndrome, which increases their chances of having
complications after birth.”
2. “When infants are born two or more weeks after their due date, they have meconium in the
amniotic fluid.”
3. “Sometimes the placenta ages excessively, and we want to take care of that problem before
it happens.”
4. “The doctor wants to be proactive in preventing any problems with your baby if he gets
any bigger.”
Answer: 1,2
Rationale 1:
This statement is correct.
Rationale 2:
Although this statement is partially true, meconium-stained amniotic fluid is not always
present or the only complication of postmaturity syndrome.
Rationale 3:
Although this statement is true, it is too vague. It is better to be specific and call postmaturity
syndrome by its name.
Rationale 4:
Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an
issue.
7) The nurse is working with a family that just experienced the birth of their first child at 34
weeks. Which statements indicate that additional teaching is needed?
1. “Our baby will be in an isolette to keep him warm.”
2. “Breathing might be harder for our baby because he is early.”
3. “The growth of our baby will be faster than if he were term.”
4. “Tube feedings will be required because his stomach is small.”
5. “Because he came early, he will not produce urine for two days.”
Answer: 3,4,5
Rationale 1:
Preterm infants have little subcutaneous fat and have difficulty maintaining their body
temperature. An isolette or overhead warmer is used to keep the baby warm.
Rationale 2:
Surfactant production might not be complete at 34 weeks, which leads to respiratory distress
syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains
patent, which is common in preterm infants.
Rationale 3:
Preterm infants grow more slowly than do term infants.
Rationale 4:
Although tube feedings might be required, it would be because preterm babies lack sufficient
suck and swallow reflexes to prevent aspiration.
Rationale 5: Although preterm babies have diminished kidney function due to incomplete
development of the glomeruli, they will make urine.
8) The nurse is caring for an infant with abdominal contents protruding out approximately at
the location of the umbilicus. What is the primary mechanism used to differentiate between
omphalocele or gastroschisis?
1. With omphalocele, the abdominal contents are covered with a sac; with gastroschisis, the
abdominal contents are not covered by a sac.
2. With omphalocele, the abdominal contents are not covered with a sac; with gastroschisis,
the abdominal contents are covered by a sac.
3. With omphalocele, the abdominal contents protrude to the right of an intact umbilical cord;
with gastroschisis, the abdominal contents protrude into the base of the umbilical cord.
4. With omphalocele, the abdominal contents protrude into the base of the umbilical cord;
with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord.
Answer: 4
Rationale 1:
If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal
contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better
way to differentiate between omphalocele and gastroschisis is that the abdominal contents
protrude into the base of the umbilical cord in omphalocele but protrude to the right of the
umbilical cord in gastroschisis.
Rationale 2:
If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal
contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better
way to differentiate between omphalocele and gastroschisis is that the abdominal contents
protrude into the base of the umbilical cord in omphalocele but protrude to the right of the
umbilical cord in gastroschisis.
Rationale 3:
This is the opposite description of gastroschisis and omphalocele. With omphalocele, the
abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the
abdominal contents protrude to the right of an intact umbilical cord.
Rationale 4:
This is a correct way to differentiate between omphalocele and gastroschisis.
9) The nurse is assessing a 36-week gestational age newborn. Upon auscultation, she hears a
late systolic murmur in the left intrascapular area with no femoral pulse but increased
brachial pulses. What treatment should this infant receive?
1. Indomethacin with surgical ligation.
2. Lanoxin with surgical closure with a Dacron patch.
3. Prostaglandin E1 and surgical resection of the aorta.
4. Palliative surgery to increase blood flow to the lungs followed by corrective surgery.
Answer: 3
Rationale 1:
This treatment is used with patent ductus arteriosus. This infant has coarctation of aorta,
which should be treated with prostaglandin E1 and surgical resection of the aorta.
Rationale 2:
This treatment is used for ventricular septal defect. This infant has coarctation of aorta, which
should be treated with prostaglandin E1 and surgical resection of the aorta.
Rationale 3:
This is the correct treatment for an infant with coartation of aorta.
Rationale 4:
This treatment is used for tetralogy of Fallot. This infant has coarctation of aorta, which
should be treated with prostaglandin E1 and surgical resection of the aorta.
10) The nurse is caring for a newborn in the special care nursery. The infant is positioned
prone and has hydrocephalus. The nurse is especially careful to cleanse all stool after bowel
movements. This care is most appropriate for an infant born with:
1. Omphalocele.
2. Gastroschisis.
3. Diaphragmatic hernia.
4. Myelomeningocele.
Answer: 4
Rationale 1:
Omphalocele is a herniation of abdominal contents into the base of the umbilical cord.
Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with
omphalocele.
Rationale 2:
Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal
organs’ being located on the outside of the body. Positioning on the abdomen would be
detrimental. Hydrocephalus is not associated with this condition.
Rationale 3:
Diaphragmatic hernia is incomplete formation of the diaphragm, resulting in bowel and
sometimes stomach extending upward through the defect and being located in the chest
cavity. Respiratory distress is the primary symptom. Surgical repair is required for normal
respiratory function if the lungs have not been compromised by crowding from abdominal
organs. Positioning should be high Fowler’s to facilitate respiratory efforts. Hydrocephalus is
not associated with this condition.
Rationale 4:
Myelomeningocele is a neural tube defect in which the meninges and spinal cord are
exposed. Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the
perineum helps prevent infection. The infant is positioned prone to prevent pressure on the
defect. Hydrocephalus often is present.
11) Parents have been told their child has fetal alcohol syndrome. Which statement indicates
that additional teaching is required?
1. “Our baby’s heart murmur is from this syndrome.”
2. “He might be a fussy baby because of this.”
3. “His face looks like it does due to this problem.”
4. “Cuddling and rocking will help him stay calm.”
Answer: 4
Rationale 1:
Ventral and atrial septal defects are common in babies with FAS.
Rationale 2:
FAS babies are easily overstimulated and have feeding difficulties, leading to more crying
than an average baby.
Rationale 3:
Facial characteristics of the FAS child include a broad and flat nasal bridge, wide-set eyes,
small chin, and smooth philtrum.
Rationale 4:
FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A
dark and quiet environment helps keep the child calm.
12) The nurse is caring for a newborn born to a drug-addicted mother. Which of the
following assessment findings would be common for this newborn?
1. Hyperirritability
2. Decreased muscle tone
3. Exaggerated reflexes
4. Depressed respiratory effort
5. Transient tachypnea
Answer: 1,3,5
Rationale 1:
Hyperirritability (Choice 1) is commonly observed in newborns born to drug-addicted
mothers. These infants may exhibit increased irritability and agitation as a manifestation of
withdrawal symptoms from exposure to drugs in utero.
Rationale 2:
Decreased muscle tone (Choice 2) is less commonly associated with newborns born to drugaddicted mothers. Instead, these infants may present with hypertonia or increased muscle tone
due to central nervous system effects of prenatal drug exposure.
Rationale 3:
Exaggerated reflexes (Choice 3) are frequently noted in newborns born to drug-addicted
mothers. These infants may display hyperactive reflexes as a result of central nervous system
excitability or withdrawal symptoms from maternal drug use during pregnancy.
Rationale 4:
Depressed respiratory effort (Choice 4) can occur in newborns born to drug-addicted
mothers, but it is not typically a prominent finding. Instead, these infants may experience
respiratory distress due to transient tachypnea (Choice 5) or other respiratory complications
associated with prematurity or maternal drug use.
Rationale 5:
Transient tachypnea (Choice 5) is a common respiratory complication observed in newborns
born to drug-addicted mothers. It is characterized by rapid breathing shortly after birth due to
delayed clearance of fetal lung fluid and can lead to respiratory distress. This condition
usually resolves within the first few days of life.
13) Which of the following should be considered potentially infectious when providing
nursing care for a newborn with an HIV-positive mother?
1. Soiled linens
2. Urine
3. Blood
4. Mask worn while caring for infant
5. Feces
Answer: 1,2,3,5
Rationale 1:
Soiled linens (Choice 1) can potentially be infectious when providing nursing care for a
newborn with an HIV-positive mother. HIV can survive in blood and other bodily fluids for a
short period, and contaminated linens may pose a risk of transmission if proper infection
control measures are not followed.
Rationale 2:
Urine (Choice 2) can also potentially be infectious, as HIV can be present in urine if the virus
is present in the mother's bloodstream. Although the concentration of HIV in urine is
generally lower compared to blood, precautions should still be taken to prevent exposure.
Rationale 3:
Blood (Choice 3) is a known source of HIV transmission. Nursing care involving contact
with blood from the newborn or the mother carries a risk of HIV transmission if appropriate
infection control practices are not followed.
Rationale 4:
A mask worn while caring for the infant (Choice 4) does not pose a risk of HIV transmission.
HIV is primarily transmitted through exposure to infected blood, sexual contact, or from
mother to child during childbirth or breastfeeding. Wearing a mask is not directly related to
HIV transmission prevention unless it is used in conjunction with other infection control
practices during procedures involving potential exposure to blood or bodily fluids.
Rationale 5:
Feces (Choice 5) can potentially contain HIV if the virus is present in the mother's
bloodstream. While the risk of HIV transmission through feces is lower compared to blood,
precautions should still be taken to prevent exposure, especially during diaper changes or
handling of contaminated materials.
14) The family of a newborn has just been told their infant has tetralogy of Fallot. The family
does not seem to understand the explanation given by the physician. What statement by the
nurse is best?
1. “With this defect, not enough of the blood circulates through the lungs, leading to a lack of
oxygen in the baby’s body.”
2. “The baby’s aorta has a narrowing in a section near the heart that makes the left side of the
heart work harder.”
3. “The blood vessels that attach to the ventricles of the heart are positioned on the wrong
sides of the heart.”
4. “Your baby’s heart doesn’t circulate blood well because the left ventricle is smaller and
thinner than normal.”
Answer: 1
Rationale 1:
Tetralogy of Fallot is a cyanotic heart defect that is comprised of four abnormalities:
pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle
hypertrophy. Deoxygenated blood is shunted from the right ventricle through the VSD into
the left ventricle, bypassing the lungs and circulating de-oxygenated blood.
Rationale 2:
This describes coarctation of the aorta, which is not a cyanotic heart defect but an obstructive
defect to systemic blood flow.
Rationale 3:
This describes transposition of the great vessels.
Rationale 4:
This describes hypoplastic left heart syndrome.
15) The nurse is preparing an educational session on phenylketonuria for a family whose
neonate has been found to have the condition. Which statement indicates that teaching was
effective?
1. “This condition occurs more frequently among Japanese people.”
2. “We must be very careful to avoid most proteins to prevent brain damage.”
3. “This condition will resolve itself by the time my child reaches the age of 5.”
4. “The thyroid gland of our baby isn’t functioning properly.”
Answer: 2
Rationale 1:
Japanese people have a very low rate of PKU disease; it is most common among northern
Europeans.
Rationale 2:
PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein
sources. High phenylalanine levels cause brain damage and severe neurologic abnormalities.
Rationale 3:
PKU is a genetic disorder, so the child will have the condition for his or her entire life.
Rationale 4:
Congenital hypothyroidism is the disorder of low thyroid function at birth.
