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The pediatric nurse prepares a newborn for phototherapy. The nurse explains to the parents that certain organs need to be protected during treatment. Which organs are these? A. Eyes and ears B. Eyes and hands C. Eyes and genitals D. Genitals and hands C ~ Phototherapy uses daylight and cool white, blue, or special blue fluorescent light tubes. These lights are the most effective form of phototherapy and are placed around and above the newborn. The eyes and genitals of the newborn are always covered to prevent tissue and retinal damage. The hands and ears of the newborn are not damaged by phototherapy. The pediatric nurse is receiving a morning report via phone call on an infant who will be arriving in the neonatal intensive care unit. The report indicates that shoulder dystocia may have occurred during the birth process. The nurse assesses the neonate as at risk for which additional condition? A. Brachial plexus injury B. Hyperbilirubinemia C. Hypoglycemia D. Intracranial hemorrhage A ~ Risk factors for a brachial plexus injury include LGA or macrosomic newborns, newborns with a diabetic mother, instrument delivery, prolonged labor, shoulder dystocia, and multiparity. The pediatric nurse explains to the nursing student that respiratory distress syndrome results from a developmental lack of which substance? A. Calcium B. Lecithin C. Magnesium D. Surfactant D ~ Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The other substances are not related to this disorder.
A baby with brachial plexus injury is being discharged home. What information should the nurse include on the teaching plan? A. Encourage the baby to move the arm by holding out toys to reach for. B. Keep the baby's arm in the sling for 23 out of every 24 hours. C. Perform passive range-of-motion exercises to affected extremity. D. Return to the hospital on day 7 for microsurgical repair. C ~ Brachial plexus injuries (BPI) manifest by lack of movement of an arm, elbow, wrist, or hand. The arm is initially rested, then after 5 to 10 days, passive range of motion (ROM) is started. Parents are taught to do the passive ROM several times a day. This baby is too young to reach for toys and active movement is not encouraged. The baby does not need a sling. Microsurgical repair is indicated if repair is needed, but day 7 would be too early. A postterm baby is born, and the nurse notes that the baby has dirty-looking skin and nails. The baby has moderate respiratory distress with rales and rhonchi noted. What nursing care does the nurse anticipate providing for this infant? A. Giving the baby oxygen via an oxygen hood B. Increasing oxygenation by using CPAP C. Providing chest physiotherapy every 8 hours D. Sitting the infant upright to feed and sleep B ~ This baby has a dirty appearance because he or she was born in meconium- stained amniotic fluid, and the respiratory manifestations signal meconium aspiration syndrome. To improve oxygenation, treatment often involves CPAP. Less invasive means of providing oxygen (the hood) are usually not adequate. Chest physiotherapy is usually done every 3 to 4 hours. Sleeping and feeding in an upright position is helpful for GERD.
A preterm infant in the NICU is receiving oxygen, and the nurse notes that the oxygen saturation is 98%. Which action by the nurse is most appropriate? A. Call respiratory therapy to draw an arterial blood gas. B. Document the findings and continue to monitor. C. Lower the infants oxygen concentration and reassess. D. See if the infant can tolerate more stimulation and activity. C ~ Preterm infants receiving oxygen should only receive the amount of oxygen needed to maintain an oxygen saturation of greater than 92%, due to the risk of developing retinopathy of prematurity (ROP). Because this babys O2 saturation is well above this reading, the nurse can try to reduce the flow and reassess. ABGs are not warranted. The nurse should document the findings, but further action is needed. Assessing activity tolerance is an ongoing assessment and is not related to preventing ROP. A nurse explains to a student that which of the following is the mechanism by which circulation of oxygen is increased to the organs of a newborn? A. Deeper respirations B. Increased stroke volume C. Increased tidal volume D. Tachycardia D ~ In a newborn, ability to alter cardiac output is limited, and stroke volume cannot be improved. The physiological mechanism by which circulation of oxygenated blood to organs is improved in the newborn is tachycardia. A woman gave birth to an infant weighing 390 g. Which action by the NICU charge nurse is most appropriate? A. Begin the discharge planning process when the child is admitted. B. Consult social services to help make arrangements for home care. C. Consult the palliative care team and admit the infant for comfort care. D. Prepare for aggressive resuscitation and admission to the NICU. C ~ Very premature infants present moral and ethical dilemmas regarding their care. According to the International Liaison Committee on Resuscitation, infants born at less than 23 weeks gestation or weighing less than 400 g are not candidates for resuscitation. The nurse should plan to admit this infant for comfort care only. The other options are not warranted.
A nurse is preparing to admit a newborn to the NICU who weighs 1,750 g. What classification does the nurse use to describe this infant? A. Extremely low birth weight B. Low birth weight C. Normal birth weight D. Very low birth weight B ~ A normal birth weight baby is between the 10th and 90th percentile on the developmental growth chart for developmental age. A low-birth-weight baby is a newborn weighing less than 2,500 g. A very-low-birth-weight infant weighs less than 1,500 g, and an extremely low-birth-weight infant weighs less than 1,000 g. A small-for-gestational-age (SGA) newborn is admitted to the NICU. The nurse notes that the baby's head circumference is in the 68th percentile for gestational age, but the baby's weight is under the 10th percentile. The baby also has a scaphoid abdomen and long fingernails. How does the nurse classify this baby in the handoff report? A. Asymmetrical intrauterine growth restriction B. Cold-stressed infant C. Intrauterine growth retardation D. Small for gestational age A ~ An SGA newborn has a weight under the 10th percentile for gestational age. This results from intrauterine growth restriction (IUGR). A baby with symmetrical IUGR has low weight plus a head circumference that falls below the 10th percentile. Asymmetrical IUGR results in weight under the 10th percentile and a head of an appropriate size. The terminology intrauterine growth retardation is no longer used. This baby is not cold stressed. A nurse is assessing a newborn infant and notes cool skin, poor feeding attempts, and bradycardia. Which action by the nurse is best? A. Obtain a rectal temperature. B. Place the infant in a radiant warmer. C. Provide a neutral thermal environment. D. Put the infant on a warm pack. A ~ This infant appears to be hypothermic, but the diagnosis of hypothermia is based on a rectal temperature in addition to the characteristic signs, so the nurse needs to do that first. Then the nurse can place the infant under a radiant warmer or on a warm pack. Infants should be provided with a neutral thermal environment at all times, but this will not warm this baby fast enough on its own.
A nurse assesses a premature infant and finds shearing injuries to the infants’ arms and legs. What action by the nurse is best? A. Apply emollient lotion to the skin. B. Assess the baby for pain. C. Order hypoallergenic crib linens. D. Place sheepskin under the baby. B ~ Skin breakdown due to rubbing and shearing is a common occurrence in a baby with unrelieved pain. The nurse should first assess the baby for pain and treat accordingly. Emollient should not be used on open skin. Hypoallergenic linens are not warranted. Sheepskin may or may not be helpful, but the best action is to assess and treat any pain. A nurse has given a premature hypoglycemic infant an IV glucose solution. How would the nurse best determine if the goals for this treatment have been met? A. Blood glucose is 42 mg/dL. B. Blood glucose is 58 mg/dL. C. The baby has a normal-sounding cry. D. The baby is sucking vigorously. B ~ Many nurseries consider a high-risk newborn hypoglycemic when blood glucose readings are below 5060 mg/dL. For this premature infant, a glucose of 58 mg/dL indicates that treatment has been effective. A blood glucose of 42 mg/dL would be acceptable for a healthy newborn. One sign of hypoglycemia is a high- pitched or weak cry, so this might be an assessment finding associated with euglycemia; however, it is not as specific as a laboratory test. Vigorous sucking is not related. A 2-hour-old infant has ruddy skin and delayed capillary refill. What laboratory value best correlates with this condition? A. Blood glucose is 38 mg/dL. B. Blood glucose is 65 mg/dL. C. Hematocrit is 42%. D. Hematocrit is 72%. D ~ This infant has some characteristic signs of polycythemia (ruddy skin, delayed capillary refill). The diagnosis of this disorder is based on a hematocrit of 65% or greater. A hematocrit of 42% is low. Blood glucose is not related.
The nurse caring for small-for-gestational-age (SGA) infants assesses them for attainment of outcomes related to nursing diagnoses. Which assessment finding best demonstrates attainment of priority outcomes? A. Body temperature of 97.5F (36.4 C) B. Gains weight regularly C. Parents visit daily D. Skin remains intact B ~ The SGA infant has several important nursing diagnoses, including risk for activity intolerance related to increased metabolic needs, risk for ineffective feeding pattern related to increased metabolic need, and nutritional imbalance related to hypoglycemia. The fact that this infant is gaining weight demonstrates that he or she is meeting outcomes related to all three diagnoses. A body temperature of 97.5F is too cool for removal of the baby from the incubator. Parental involvement may indicate no unmet psychosocial needs on their part, but physical diagnoses take precedence over psychosocial ones. Intact skin is a good finding, but risk for impaired skin integrity would not be a higher priority than the other three. A newborn has a blood glucose level of 188 mg/dL. What further assessment on this baby takes priority? A. Airway status B. Breathing status C. Circulatory status D. Skin status C ~ Hyperglycemia causes an osmotic diuresis and can lead to dehydration. The nurse needs to prioritize the assessment of fluid status over the other assessments.
A nurse sees a baby whose left arm is in a flexed position and is held in place by pinning the cuff of the baby's T-shirt sleeve to the opposite shoulder. What can the nurse conclude about this baby? A. Broken clavicle B. Broken wrist C. Duchenne-Erb paralysis D. Klumpke paralysis A ~ A broken clavicle is often treated by pinning the infants arm as described. Duchenne-Erb paralysis is a type of brachial plexus injury caused by nerve injury to C5T1. Klumpke paralysis is another type of brachial plexus injury caused by nerve injury to C5C7. Wrist fractures in infants are uncommon. The nurse working in labor and delivery knows that which infant is at highest risk of having a long-bone fracture? A. Intrauterine growth restriction B. Mother with osteoporosis C. Multiples with one breech presentation D. Premature C ~ Risk factors for long-bone fractures include breech presentation, multiples, prematurity, and fetal osteoporosis. The premature baby has some risk, but not as much as multiple births with one breech presentation. A preterm infant was born at 31 weeks and has been admitted to the NICU. The nurse notes expiratory grunting, nasal flaring, and cyanosis on room air. Which laboratory findings would correlate with this condition? A. PaCO2: 56 mm Hg B. PaO2: 76 mm Hg C. pH: 7. D. SaO2: 94% A ~ This premature infant is at risk for respiratory distress syndrome (RDS) and has classic signs of the disorder. Laboratory values consistent with this condition are hypercarbia, metabolic acidosis, and low measured levels of oxygen either by arterial blood gas analysis or oxygen saturation. Normal PaCO2 for infants is 3540 mm Hg, so this level is high. The other values are normal.
A premature infant has apnea of prematurity accompanied by bradycardia and desaturation. The infant was started on caffeine citrate (Cafcit), and the results from a blood level have just now returned. The infants blood level of Cafcit is 2.3 mg/mL. What action by the nurse is most appropriate? A. Allow infant to grow out of the current Cafcit dose. B. Document results; maintain cardiorespiratory monitor. C. Inform parents that this blood level is therapeutic. D. Prepare for immediate intubation and ventilation. B ~ The therapeutic blood level for caffeine citrate (Cafcit) is 520 mg/mL; therefore, this blood level is subtherapeutic. The nurse should document the results and continue monitoring the infant with the cardiorespiratory monitor. The physician should also be informed so the dose can be adjusted if warranted. The child should not be allowed to outgrow the dose for weaning as the apnea and bradycardia episodes continue. The parents should not be informed that the level is therapeutic because it is not. There is no information leading to a conclusion that the infant needs intubation and mechanical ventilation. A nurse is caring for a premature infant on oxygen. What action is critical for the infants safety? A. Educate the parents to care for an infant on oxygen. B. Keep the infant in an incubator while on oxygen. C. Obtain daily chest x-rays to monitor lung maturity. D. Use the lowest amount of oxygen possible. D ~ Although oxygen therapy is often needed, it has complications, one of which is bronchopulmonary dysplasia (BPD). The use of supplemental oxygen results in lungs that fail to develop normal compliance. Preventative measures for BPD include using the lowest amount of oxygen needed to keep saturations in the desired range. If the child goes home on oxygen, the parents will need to be taught how to care for the baby. Lung maturity is assessed on the basis of function, not daily chest x-rays. The infant may need a warmer due to prematurity and inability to regulate temperature, but this is not a safety measure related to oxygen.
A postterm newborn is being treated for persistent pulmonary hypertension. Which assessment finding best indicates that a priority outcome has been met? A. Blood pressure in normal range for age B. Maintains temperature C. Oxygen saturation 95% D. Weight gain C ~ A priority outcome for this patient is maintenance of oxygen saturation in the normal range. The other assessment findings are good but do not relate to the primary outcome. A nurse is asked to record preductal and postductal oxygen saturations on an infant with possible persistent pulmonary hypertension. Where does the nurse assess the preductal saturation? A. Earlobe B. Left finger C. Left great toe D. Right finger D ~ Measuring the preductal (right radial) pulse oximetry and comparing it to the postductal (left radial) can help diagnose persistent pulmonary hypertension. A difference of 5% or more demonstrates the right-to-left shunt that this condition produces. A child diagnosed with congenital hypothyroidism is being dismissed from the NICU. What information should the nurse plan to teach the parents? A. Avoid foods such as fish, milk, or meat-based broth soups. B. The correct dose of levothyroxine (Synthroid) is 1015 mg/kg/day. C. The correct dose of levothyroxine (Synthroid) is 1015 mg/kg/day. D. Regular eye examinations should be undertaken every 6 months. C ~ The treatment for congenital hypothyroidism is Synthroid, the dose of which is 1015 mg/kg/day. The other dose is too high. Avoiding fish, milk, and meat- based broths is part of the diet for homocystinuria. Regular eye exams are not part of the treatment plan for hypothyroidism.
A baby has just been born with anencephaly. Which action by the labor and delivery charge nurse takes priority? A. Admit the baby to the NICU. B. Consult the palliative care team. C. Place the infant in protective isolation. D. Prepare the infant for surgery. B ~ Anencephaly is a condition in which the child is born with a malformed skull and cerebrum. Some children with anencephaly are born alive, but the condition is fatal, as most of the skull is not present. The priority for the charge nurse is to initiate spiritual and palliative care for the family. There is no indication for admission to the NICU, protective isolation, or surgery. An infant is born with an encephalocele. Which action by the nurse takes priority? A. Admit the baby to the NICU. B. Consult the palliative care team. C. Place warm sterile gauze on the defect. D. Prepare the infant for surgery. C ~ The priority action is to place sterile gauze over the open defect to prevent infection. The infant will need surgery and admission to the NICU, but the first action to take is to protect the baby's safety. The mortality rate is fairly high, but the first choice would not be to consult the palliative care team, as surgery is usually attempted to repair the defect. A pediatric nurse sees a baby with microcephaly. What action is most important for this nurse to do? A. Assess the baby's feeding abilities with an adapted nipple. B. Document head circumference at each visit. C. Document weight gain at each visit. D. Review medication administration with parents. B ~ A baby with microcephaly has a head circumference 2 standard deviations below the mean for gestational age. It is crucial for the nurse to accurately and consistently measure and document the baby's head circumference at each visit. The baby does not need a special nipple. Documenting weight gain is important for every baby, but is not specific for this condition. There are no medications used to treat this condition.
A premature infant was delivered after a prolonged labor with rupture of the maternal membranes >18 hours. The infants weight is 6 lb, 1 oz (2.75 kg). What assessment finding would require the nurse to intervene immediately? A. Blood pressure reading of 60/35 mm Hg B. Skin temperature reading of 96.8F (36C) C. Unconjugated bilirubin level of 1.0 mg/dL D. White blood cell count of 12,500/mm B ~ This infant is at risk for neonatal sepsis. Signs of this condition include hyperthermia or hypothermia, lethargy, hypoglycemia, and poor feeding. This child's skin temperature reading is below normal, requiring the nurse to intervene. The blood pressure reading is normal for a child of this weight. The two laboratory values are also normal. A nurse is explaining to a student that sudden infant death syndrome (SIDS) has been reduced due mostly to what trend? A. A decrease in preterm births B. Decreased maternal smoking C. Fewer drug-addicted mothers D. The Back to Sleep campaign D ~ The Back to Sleep campaign of the American Academy of Pediatrics aims for all infants to sleep on their backs, every time. Since initiation of this campaign, there a has been a 50% reduction in SIDS deaths. The other factors are not as firmly related to SIDS as is sleeping supine. A premature newborn has a pulse pressure of 33 mm Hg. What action by the nurse takes priority? A. Assess the infant for patent ductus arteriosus. B. Ensure the blood pressure cuff is the right size. C. Increase fluids to 1.5 times the maintenance rate. D. Sedate the baby to prevent fighting the ventilator. B ~ A normal pulse pressure in a premature infant is 1525 mm Hg. This widened pulse pressure could be indicative of a patent ductus, so the nurse should assess for this condition. However, the first action would be to ensure that the blood pressure cuff is the appropriate size and is calibrated correctly. Increasing IV fluids and sedating the baby are not indicated.
A premature infant is born and admitted to the NICU. A student nurse questions why the primary nurse is starting to plan discharge teaching so early. Which response by the nurse is best? A. All these babies have the same needs, so discharge planning here is pretty routine. B. By starting early I can ensure that social work and specialty nurses can see the baby. C. I'm not really planning the baby's discharge; I'm just writing some notes about it. D. The parents have so much to learn we have to start planning discharge on admission. D ~ Discharge planning starts on admission to the NICU. Instructions are extensive and parents need time to absorb education and begin planning. Of course, changes in the baby's condition warrant changes in plans, but by starting early, the nurse can ensure the best possible outcome for the family. A nurse preceptor of a student nurse explains that although a high-risk newborn can have complications in any body system, the systems most often impacted include which of the following? (SATA) A. Circulatory B. Integumentary C. Neurological D. Renal E. Respiratory A, C, E ~ The three systems most commonly affected in the high-risk newborn are the circulatory, respiratory, and neurological systems. A nurse monitors all newborns in the NICU for hypoglycemia. Which manifestations could indicate hypoglycemia in one of the babies? (SATA) A. Apneic episodes B. None (asymptomatic) C. Eye rolling D. Lethargy E. Palmar sweating A, B, C, D ~ Apneic episodes, eye rolling, and lethargy are among the manifestations of hypoglycemia. Hypoglycemic infants can also be asymptomatic. Palmar sweating is indicative of pain.
A baby was born 4 days ago at 34 weeks gestation and is receiving phototherapy for neonatal jaundice. The baby has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. What are the nurses priority nursing interventions? (SATA) A. Assess the baby's temperature to check for hypothermia. B. Check to make sure the infant's face mask stays in place. C. Educate the mother to feed the child every 2 hours. D. Verify laboratory results to check for hypoglycemia. E. Verify laboratory results to check for hypomagnesemia. A, D ~ Priority nursing actions for the baby undergoing phototherapy include keeping the baby warm, as hypothermia can occur due to exposure, and ensuring the baby receives adequate nutrition. Bilirubin is excreted in the stool. Proper nutrition will also help maintain fluid status. Keeping the baby's mask in place is an important safety action to prevent eye damage, but is not related to this baby's signs. Hypoglycemia can occur with poor nutrition. Magnesium levels are not affected by jaundice. An infant has been admitted to the neonatal intensive care unit because of meconium-aspiration syndrome and related complications. The pediatric nurse assesses the patient frequently for which complication? (SATA) A. Hemothorax B. Pneumomediastinum C. Pneumonia D. Pneumothorax E. Respiratory distress syndrome. B, D ~ Meconium-aspiration syndrome is often complicated by pneumothorax and/or pneumomediastinum. Hemothorax, pneumonia, and respiratory distress syndrome are not typical complications.
A nurse is caring for a baby with neonatal abstinence syndrome. Which of the following medications should the nurse be prepared to give? (SATA) A. Chlorpromazine (Thorazine) B. Clonidine (Catapres) C. Diazepam (Valium) D. Phenobarbital (Luminal) E. Naloxone (Narcan) A, B, C, D ~ Several medications are used to treat the infants of drug-abusing mothers, including paregoric (camphorated tincture of opium), phenobarbital (Luminal), clonidine (Catapres), chlorpromazine (Thorazine), and diazepam (Valium). Naloxone (Narcan) is not used because it can increase the severity of drug withdrawal in the infant. An experienced NICU nurse is explaining to a new nurse why premature infants have such great nutritional needs. What information should the experienced nurse include? (SATA) A. The pancreas doesn't produce enough insulin for food use. B. Their guts are premature and don't absorb nutrients. C. They haven't built up stores in-utero like term babies. D. They have complications that increase their metabolic rate. E. They lose 10% of their already-low weight at birth. C, D, E ~ Several factors exist to cause increased nutritional demands in the premature infant. They haven't have time in the uterus to build up nutritional stores like normal term babies do, their many complications increase their metabolic rate, and they lose 10% of their body weight after birth, which they can ill afford, Certainly some premature infants have intestinal and pancreatic problems, but this is not a true statement for all.
