Preview Extract
Chapter 29
1) A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of
100, is not breathing, and is limp and bluish in color. What nursing action is best?
1. Begin chest compressions.
2. Deep suction the airways.
3. Begin bag-and-mask ventilation.
4. Assess blood pressure.
Answer: 3
Rationale 1:
Chest compressions are not initiated until the heart rate is less than 60 and respirations have
been established.
Rationale 2:
This would be appropriate if there were meconium-stained fluid. There is no information
about the amniotic fluid.
Rationale 3:
When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the
appropriate resuscitation measure.
Rationale 4:
Establishment of airway and breathing take priority over assessment of blood pressure.
2) The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The
amniotic fluid was clear. His mother had preeclampsia. His respiratory rate is 80; he is
grunting and has nasal flaring. What is the most likely cause of this infant’s condition?
1. Meconium aspiration syndrome
2. Transient tachypnea of the newborn
3. Respiratory distress syndrome
4. Prematurity of the neonate
Answer: 2
Rationale 1:
There was no meconium in the amniotic fluid, which rules out meconium aspiration
syndrome.
Rationale 2:
The infant is term and born by cesarean. He is most likely experiencing transient tachypnea
of the newborn.
Rationale 3:
The infant is not premature and therefore is not likely to be experiencing respiratory distress
syndrome.
Rationale 4:
The infant is not premature. Prematurity alone does not cause respiratory distress; the lack of
surfactant causes respiratory distress syndrome.
3) A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome
(RDS). The nurse informs the parents that the newborn is improving. Which of the following
data supports the nurse’s assessment?
1. Decreased urine output
2. Increased pulmonary vascular resistance
3. Increased PCO2
4. Increased urination
Answer: 4
Rationale 1:
As fluid moves out of the lungs and into the bloodstream, alveoli open, and kidney perfusion
increases, thereby increasing urine output.
Rationale 2:
Pulmonary vascular resistance increases with hypoxia.
Rationale 3:
Increased PCO2 results from alveolar hypoventilation.
Rationale 4:
Increased urination could be an indication that the newborn’s condition is improving.
4) The nurse is caring for an infant who delivered in a car on the way to the hospital and who
has developed cold stress. Which finding requires immediate intervention?
1. Vasoconstriction and pallor
2. Blood glucose level of 45
3. Room temperature IV running
4. Positioned under radiant warmer
Answer: 3
Rationale 1:
Vasoconstriction is the first physiologic response to a lowering temperature and will cause
pallor.
Rationale 2:
This is an adequate blood sugar in a neonate. Less than 40 is hypoglycemic.
Rationale 3:
IV fluids should be warmed prior to administration and wrapped in a blanket or other
insulating material to keep them warm. Room temperature IV fluids will increase the cold
stress.
Rationale 4:
Radiant warmers are used to gradually increase the neonate’s temperature.
5) Place the following nursing interventions related to resuscitation in the correct order
according to complexity of the method and seriousness of the infant’s condition.
Choice 1. Chest compressions
Choice 2. 21% oxygen in a positive-pressure ventilator
Choice 3. Rub the infant’s back with a blanket.
Choice 4. Administer epinephrine.
Choice 5. 100% oxygen in a positive-pressure ventilator
Answer: 3,2,5,1,4
Rationale 1:
Chest compressions should only be performed if the infant’s heart rate is below 60
beats/minute despite 30 seconds of effective positive-pressure ventilation.
Rationale 2:
If rubbing the back does not establish adequate breathing, the infant should be placed on 21%
oxygen with a positive-pressure ventilator.
Rationale 3:
Rubbing the infant’s back is the least invasive therapy and should be attempted before any
other resuscitation method.
Rationale 4:
Epinephrine should be administered when the heart rate remains below 60 beats/minute
despite 45-60 seconds of chest compressions and ventilation.
Rationale 5:
Oxygen should be increased from 21% to 100% before chest compressions begin.
6) The patient with blood type O Rh-negative has given birth to an infant with blood type O
Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks
why this is happening. The best response by the nurse is:
1. “The RhoGAM you received at 28 weeks’ gestation did not prevent alloimmunization.”
2. “Your body has made antibodies against the baby’s blood that are destroying her red blood
cells.”
3. ““The red blood cells of your baby are breaking down because you both have type O
blood.”
4. “Your baby’s liver is too immature to eliminate the red blood cells that are no longer
needed.”
Answer:
Rationale 1:
Although this statement is true, the term “alloimmunization” is not likely to be understood by
the client. It is better to explain what is happening using more understandable terminology.
Rationale 2:
This is a correct statement.
Rationale 3:
Mother and baby’s both having type O blood is not a problem. ABO incompatibility occurs if
the mother is O and the baby is A or B.
Rationale 4:
The infant’s liver is indeed too immature to eliminate red blood cells, but the hemolysis from
the maternal antibodies is the cause of the jaundice.
7) The nurse is observing a student nurse care for a neonate undergoing intensive
phototherapy. Which action by the student nurse indicates that she understands how to
provide care for an infant undergoing intensive phototherapy?
1. Urine-specific gravity is assessed each voiding.
2. Eye coverings are left off to help keep the baby calm.
3. Temperature is checked every six hours.
4. The infant is taken out of the isolette for diaper changes.
Answer: 1
Rationale 1:
This action is correct; urine concentration as indicated by raising urine-specific gravity
indicates a need for additional fluids.
Rationale 2:
Eyes should be covered at all times.
Rationale 3:
Every six hours is too infrequent; the temperature should be assessed every four hours to
prevent hyper- or hypothermia.
Rationale 4:
The infant’s care should be clustered to keep the infant under the lights as much as possible.
The diaper should have been changed while under the lights in the isolette.
8) A diabetic mother has just given birth to a baby boy. The baby appears lethargic and has a
high-pitched cry. The initial plasma glucose level was 19 mg/dL. What is the proper nursing
action for this infant?
1. Wait 30 minutes and re-test plasma glucose levels.
2. Have the mother breastfeed the infant.
3. Start an IV with D5W dextrose solution.
4. Start an IV with D10W dextrose solution.
Answer: 4
Rationale 1:
This infant is suffering from severe hypoglycemia. Aggressive treatment with D10W
dextrose by IV is recommended.
Rationale 2:
This is an appropriate nursing action if the infant’s plasma glucose levels are between 25 and
40 mg/dl. This infant needs more aggressive treatment.
Rationale 3:
D5W dextrose is primarily use to either prevent hypoglycemia or titrate down the
concentration of administered glucose when the infant is transitioning off the glucose. A
higher concentration of glucose is required for severely hypoglycemic infants.
Rationale 4:
This is the proper nursing action. Infants with severe hypoglycemia should be aggressively
treated with IV infusion of D10W dextrose.
9) A mother called the maternity ward four days after the birth of her baby girl. She tells the
nurse that she has noticed her infant’s skin tone is yellow and asks if she should bring the
infant to the hospital. What is the most likely cause of the infant’s skin tone?
1. Pathologic jaundice
2. Acute bilirubin encephalopathy
3. Physiologic jaundice
4. Hemolytic disease of the newborn
Answer: 3
Rationale 1:
Pathologic jaundice usually appears before 24 hours of life and is the result of a more serious
underlying condition.
Rationale 2:
Acute bilirubin encephalopathy, or kernicterus, is a serious medical condition resulting from
very high bilirubin levels as a result of pathologic jaundice. This is unlikely to occur with
physiologic jaundice.
Rationale 3:
Most infants will develop physiologic jaundice 4-5 days after birth as a result of a shortened
red blood cell lifespan, slow uptake of bilirubin by the liver, a lack of intestinal bacteria, or
poorly established hydration from initial breastfeeding.
Rationale 4:
Hemolytic disease of the newborn occurs as a result of blood incompatibility between the
mother and infant and is usually diagnosed shortly after birth.
10) The nurse assesses that a newborn’s skin has a ruddy appearance, and the peripheral
pulses are decreased. The nurse suspects polycythemia. Which of the following lab reports
might indicate polycythemia?
1. Venous hemoglobin level higher than 26 g/dL
2. Bilirubin level of 6 mg/dL
3. Venous hemoglobin level lower than 12 g/dL
4. Blood glucose level of 44 mg/dL
Answer: 1
Rationale 1:
A venous hemoglobin level higher than 26 g/dL indicates polycythemia.
Rationale 2:
Bilirubin level is within normal range.
Rationale 3:
A venous hemoglobin level lower than 12 g/dL indicates anemia.
Rationale 4:
Blood glucose levels are within normal range.
11) The newborn has been diagnosed with sepsis. What indications would lead the nurse to
suspect this condition?
1. Respiratory distress syndrome developed 48 hours after birth.
2. Temperature of 97.0°F two hours after warming the infant from 97.4°F
3. Irritability and flushing of the skin at 8 hours of age
4. Bradycardia and tachypnea develop when the infant is 36 hours old.
Answer: 2
Rationale 1:
Respiratory distress developing at 12–24 hours of age might indicate sepsis.
Rationale 2:
Temperature instability is often seen with sepsis. Fever is rare in a newborn.
Rationale 3:
Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, especially if
skin is cool and clammy.
Rationale 4:
Tachycardia and periods of apnea are seen with sepsis, especially within the first 24 hours of
life.
12) A 42-year-old mother was diagnosed with placenta previa, and her baby was delivered by
cesarean section at 32 weeks. At birth, the infant has a low pulse rate, low blood pressure,
and a capillary filling time of 3.6 seconds. Which of the following interventions are needed?
1. Monitor the infant’s cardiac and respiratory status.
2. Have isotonic saline ready for transfusion.
3. Draw several vials of blood for laboratory testing.
4. Start the infant on iron supplements.
5. Have O-negative packed red cells ready for a transfusion.
6. Start the infant on phototherapy.
Answer: 1,4,5
Rationale 1:
This is an appropriate nursing intervention. Monitoring the infant’s cardiac and respiratory
status will allow the nurse to detect symptoms of shock and assess the effectiveness of
treatment.
Rationale 2:
Isotonic saline transfusion is used to treat polycythemia, not anemia. This treatment would
worsen the patient’s condition.
Rationale 3:
Blood draws should be kept to a minimum for patients suffering from anemia.
Rationale 4:
Iron supplements should be given to help increase red blood cell production.
Rationale 5:
Patients with severe anemia will need a blood transfusion. If the infant’s blood type is not
known, O-negative packed red cells can be used for transfusions. If the infant’s blood type is
known, the appropriate typed and crossmatched packed red cells should be used.
Rationale 6: Phototherapy should only be started if the infant has jaundice.
13) One day after giving birth vaginally, a patient develops painful vesicular lesions on her
perineum and vulva. She is diagnosed with a primary herpes simplex II infection. The
expected care for her neonate includes:
1. Meticulous hand washing and antibiotic eye ointment administration.
2. Intravenous acyclovir (Zovirax) and contact precautions.
3. Cultures of blood and CSF and serial chest X-rays every 12 hours.
4. Parental rooming-in and four intramuscular injections of penicillin.
Answer: 2
Rationale 1:
Although meticulous hand washing by staff and parents is important, antibiotic eye ointment
is used for conjunctivitis of gonorrhea or Chlamydia.
Rationale 2:
These are appropriate cares for an infant at risk for developing herpes simplex II infection.
Rationale 3:
These cultures are appropriate, but chest X-rays are not indicated. Chest X-rays are obtained
if the neonate is thought to have group B strep pneumonia.
Rationale 4:
Parental rooming-in is encouraged, but penicillin does not treat viral illness. Penicillin is the
drug of choice for syphilis infections.
14) The mother of a severely premature infant is being allowed to see her baby for the first
time. The infant has an IV, a feeding tube, and is receiving phototherapy. He is also hooked
up to cardiac and respiratory monitors. What information or instructions should the mother
NOT receive before seeing her infant?
1. The mother should not touch her infant because the baby’s skin is fragile and could be
easily hurt.
2. The mother should not hold the infant before thoroughly washing her hands.
3. The mother should be told what her infant will look like.
4. The mother should receive a description of the equipment that is hooked up to her child.
Answer: 1
Rationale 1:
Physical contact between the mother and infant will facilitate bonding and should be
encouraged.
Rationale 2:
If the mother is going to hold her infant, she will need to thoroughly wash her hands to
decrease the risk of infection.
Rationale 3:
The nurse should prepare the mother for what her infant will look like, especially if the infant
is hooked up to several machines or tubes.
Rationale 4:
Seeing her child for the first time can be emotionally difficult for a mother, but a description
of the equipment and its purpose will help the mother understand the care her child is
receiving and help ease her anxiety.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
