CH 27: Newborn at Risk

Question 139688
Id:
139688
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MCSA
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:
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Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
37-year-old G8 P2323, works in a chemical factory
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.
Answer 1
true
Choice 2
23-year-old primip, low socioeconomic status, unmarried
Rationale 2
The main risk factor for this patient is her low socioeconomic status.
Answer 2
false
Choice 3
16-year-old primip, began prenatal care at 30 weeks
Rationale 3
This patient has two risk factors: young age and late onset of prenatal care.
Answer 3
false
Choice 4
28-year-old G2 P1001, history of gestational diabetes
Rationale 4
This patient has gestational diabetes history as her only risk factor.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Health Promotion and Maintenance
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Assessment
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Topical SubCategory:
Pearson Nursing Taxonomy #:
Taxonomy Category Comments:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 28_LO01_Q01
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Standard 1:
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LO01 - Explain the factors present at birth that indicate an at-risk newborn.
Question 139689
Id:
139689
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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:
Stimulus
Answer
Choice 1
Change from thin and underweight as a child to overweight or obese as

adolescents
Rationale 1
This long-term effect is often seen in children with fetal alcohol syndrome,
not SGA.
Answer 1
false
Choice 2
Poor fine motor coordination
Rationale 2
SGA infants are likely to develop cognitive disabilities such as poor fine
motor coordination, hyperactivity, learning disabilities, and hearing loss.
Answer 2
true.
Choice 3
Paralysis below the hips
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.
Answer 3
false
Choice 4
Permanent disfiguration
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.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Planning
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
28_LO02_Q02

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
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Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
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Learning Outcome 6:
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Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO02 - Compare the underlying etiologies of the physiologic complications

of small-for-gestational-age (SGA) newborns and preterm appropriate-forgestational-age (Pr AGA) newborns, and the nursing care management for
each.
Question 139690
Id:
139690
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
Monitor for feeding difficulties.
Rationale 1
LGA newborns are more difficult to arouse to a quiet alert state and can have
feeding difficulties.
Answer 1
false
Choice 2
Assess for facial paralysis.
Rationale 2
LGA newborns often are prone to birth trauma, such as facial paralysis, due
to cephalopelvic disproportion.
Answer 2
false
Choice 3
Monitor for signs of hyperglycemia.
Rationale 3
SGA newborns are more prone to hypoglycemia.
Answer 3
false
Choice 4
Maintain a warm environment.
Rationale 4
Hypothermia is a common complication of the SGA newborn; therefore, the

newborns environment must remain warm to decrease heat loss.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Physiological Integrity
Client Need Sub:
Reduction of Risk Potential
Nursing/Integrated
Concepts:
Nursing Process: Implementation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 28_LO02 _Q03

Source Au Title Ed:
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Writer Last Name:
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Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO02 - Compare the underlying etiologies of the physiologic complications

of small-for-gestational-age (SGA) newborns and preterm appropriate-forgestational-age (Pr AGA) newborns, and the nursing care management for
each.
Question 139691
Id:
139691
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
A 7 pound, 14 ounce girl was born to an insulin-dependent type 2 diabetic mother two hours ago. The infants
blood sugar is 45mg/dl. The best nursing action is:
Stimulus
Answer
Choice 1
Recheck the blood sugar in four hours.
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.
Answer 1
false
Choice 2
Begin an IV of 10% dextrose.
Rationale 2
45mg/dl is considered a normal blood sugar reading for a neonate. No IV is

needed.
Answer 2
false
Choice 3
Feed the baby one ounce of formula.
Rationale 3
Feeding would be appropriate if the infants blood sugar was below 40, but
this infants reading is 45 mg/dl.
Answer 3
false
Choice 4
Document the findings in the chart.
Rationale 4
A blood sugar of 45 mg/dl is a normal finding; documentation is an

appropriate action.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 28_LO03 _Q04

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
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Stakes:
Special Handling:
Comments:
admin
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO03 - Explain the impact of maternal diabetes mellitus on the newborn.
Question 139692
Id:
139692
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
An infant was born at 31-weeks gestation and weighed 1430 g. What is the correct initial feeding regimen for
this infant?
Stimulus
Answer
Choice 1
10 mg/kg/day of premature formula 24 kcal/oz.
Rationale 1
This is the correct initial feeding regimen for preterm infants with a birth
weight under 1250 g.
Answer 1
false
Choice 2
20 mg/kg/day of premature formula 24 kcal/oz.
Rationale 2
weight between 1251 and 1500 g.
Answer 2
true
Choice 3
40 mg/kg/day of postdischarge formula 22 kcal/oz.
Rationale 3
weight between 1801 and 2500 g.
Answer 3
false
Choice 4
50 mg/kg/day of term formula 20 kcal/oz.
Rationale 4
weight over 2500 g.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Basic Care and Comfort
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
28_LO05_Q05

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
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admin
Meta 4
Learning Outcome 1:
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Learning Outcome 6:
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Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO05 - Discuss the physiologic and behavioral characteristics of the preterm

newborn that predispose each body system to various complications and that
are used in developing a plan of care that includes nutritional management.
Question 139693
Id:
139693
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
Babies can develop postmaturity syndrome, which increases their chances

of having complications after birth.
Rationale 1
This statement is correct.
Answer 1
true
Choice 2
When infants are born two or more weeks after their due date, they have
meconium in the amniotic fluid.
Rationale 2
Although this statement is partially true, meconium-stained amniotic fluid is

not always present or the only complication of postmaturity syndrome.
Answer 2
true
Choice 3
Sometimes the placenta ages excessively, and we want to take care of that
problem before it happens.
Rationale 3
Although this statement is true, it is too vague. It is better to be specific and

call postmaturity syndrome by its name.
Answer 3
false
Choice 4
The doctor wants to be proactive in preventing any problems with your

baby if he gets any bigger.
Rationale 4
Although this is true, the answer is incomplete. The risk of postmaturity

syndrome is also an issue.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 28_LO04_Q06

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO04 - Compare the characteristics and potential complications that influence

nursing management of the post-term newborn and the newborn with
postmaturity syndrome.
Question 139694
Id:
139694
Type:
MCMA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Standard Text
Select all that apply.
Stimulus
Answer
Choice 1
Our baby will be in an isolette to keep him warm.
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.
Answer 1
false
Choice 2
Breathing might be harder for our baby because he is early.
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.
Answer 2
false
Choice 3
The growth of our baby will be faster than if he were term.
Rationale 3
Preterm infants grow more slowly than do term infants.
Answer 3
true
Choice 4
Tube feedings will be required because his stomach is small.
Rationale 4
Although tube feedings might be required, it would be because preterm

babies lack sufficient suck and swallow reflexes to prevent aspiration.
Answer 4
true
Choice 5
Because he came early, he will not produce urine for two days.
Rationale 5
Although preterm babies have diminished kidney function due to incomplete

development of the glomeruli, they will make urine.
Answer 5
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Evaluation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Source Au Title Ed:
Chapter 28_LO05_Q07
Source Usage:
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO05 - Discuss the physiologic and behavioral characteristics of the preterm

newborn that predispose each body system to various complications and that
are used in developing a plan of care that includes nutritional management.
Question 139695
Id:
139695
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
With omphalocele, the abdominal contents are covered with a sac; with
gastroschisis, the abdominal contents are not covered by a sac.
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.
Answer 1
false
Choice 2
With omphalocele, the abdominal contents are not covered with a sac; with
gastroschisis, the abdominal contents are covered by a sac.
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.
Answer 2
false
Choice 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.
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.

Answer 3
false
Choice 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.
Rationale 4
This is a correct way to differentiate between omphalocele and gastroschisis.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Physiological Adaptation
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
28_LO06_Q08
Source Au Title Ed:

Source Usage:
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO06 - Summarize the nursing assessments of and initial interventions for a

newborn with selected congenital anomalies.
Question 139696
Id:
139696
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
Indomethacin with surgical ligation.
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.
Answer 1
false
Choice 2
Lanoxin with surgical closure with a Dacron patch.
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.
Answer 2
false
Choice 3
Prostaglandin E1 and surgical resection of the aorta.
Rationale 3
This is the correct treatment for an infant with coartation of aorta.
Answer 3
true
Choice 4
Palliative surgery to increase blood flow to the lungs followed by corrective

surgery.
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.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:
Reduction of Risk Potential
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
28_LO09_Q09

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
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Stakes:
Special Handling:
admin
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
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Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
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Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO09 - Identify the physical examination findings during the early newborn
period that would make the nurse suspect a congenital cardiac defect or
congestive heart failure.
Question 139697
Id:
139697
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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:
Stimulus
Answer
Choice 1
Omphalocele.
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.
Answer 1
false
Choice 2
Gastroschisis.
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.
Answer 2
false
Choice 3
Diaphragmatic hernia.
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 Fowlers to facilitate respiratory efforts.
Hydrocephalus is not associated with this condition.
Answer 3
false
Choice 4
Myelomeningocele.
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.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Source Au Title Ed:
Source Usage:
28_LO06_Q10
Writer First Name:
admin
Writer Last Name:

Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO06 - Summarize the nursing assessments of and initial interventions for a

newborn with selected congenital anomalies.
Question 139698
Id:
139698
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
Parents have been told their child has fetal alcohol syndrome. Which statement indicates that additional
teaching is required?
Stimulus
Answer
Choice 1
Our babys heart murmur is from this syndrome.
Rationale 1
Ventral and atrial septal defects are common in babies with FAS.
Answer 1
false
Choice 2
He might be a fussy baby because of this.
Rationale 2
FAS babies are easily overstimulated and have feeding difficulties, leading to
more crying than an average baby.
Answer 2
false
Choice 3
His face looks like it does due to this problem.
Rationale 3
Facial characteristics of the FAS child include a broad and flat nasal bridge,
wide-set eyes, small chin, and smooth philtrum.
Answer 3
false
Choice 4
Cuddling and rocking will help him stay calm.
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.
Answer 4
true
Global Rationale
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Nursing Process: Evaluation
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 28_LO07_Q11

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
admin
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO07 - Explain the special care needed by an alcohol- or drug-exposed

newborn.
Question 139699
Id:
139699
Type:
MCMA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Standard Text
Stimulus
Answer
Choice 1
Hyperirritability
Rationale 1
Answer 1
true
Choice 2
Decreased muscle tone
Rationale 2
Answer 2
false
Choice 3
Exaggerated reflexes
Rationale 3
Answer 3
true
Choice 4
Depressed respiratory effort
Rationale 4
Answer 4
false
Choice 5
Transient tachypnea
Rationale 5
Answer 5
true
Global Rationale
Newborns born to drug-addicted mothers exhibit hyperirritability, exaggerated reflexes, and transient
tachypnea.
Meta 1
Cognitive Level:
Applying
Client Need:
Client Need Sub:
Physiological Adaptation
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
28_LO07_Q12

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
admin
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO07 - Explain the special care needed by an alcohol- or drug-exposed

newborn.
Question 139700
Id:
139700
Type:
MCMA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
Which of the following should be considered potentially infectious when providing nursing care for a newborn
with an HIV-positive mother?
Standard Text
Stimulus
Answer
Choice 1
Soiled linens
Rationale 1
Answer 1
true
Choice 2
Urine
Rationale 2
Answer 2
true
Choice 3
Blood
Rationale 3
Answer 3
true
Choice 4
Mask worn while caring for infant
Rationale 4
Answer 4
false
Choice 5
Feces
Rationale 5
Answer 5
true
Global Rationale
Body fluids such as blood, urine, and feces are considered potentially infectious. Therefore, soiled linens are
also potentially infectious. A mask is not routinely used when caring for an infant exposed to HIV and will
likely not be contaminated if used.
Meta 1
Cognitive Level:
Analyzing
Client Need:
Safe Effective Care Environment
Client Need Sub:
Safety and Infection Control
Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
28_LO08_Q13

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
admin
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO08 - Relate the consequences of maternal HIV/AIDS to the nursing care

management of infants at risk for HIV/AIDS in the neonatal period and the
issues for their caregivers.
Question 139701
Id:
139701
Type:
MCSA
Calculator
:
false
Question
Title:
Difficulty
Level:
Question Stem
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?
Stimulus
Answer
Choice 1
With this defect, not enough of the blood circulates through the lungs,
leading to a lack of oxygen in the babys body.
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.
Answer 1
true
Choice 2
The babys aorta has a narrowing in a section near the heart that makes the
left side of the heart work harder.
Rationale 2
This describes coarctation of the aorta, which is not a cyanotic heart defect
but an obstructive defect to systemic blood flow.
Answer 2
false
Choice 3
The blood vessels that attach to the ventricles of the heart are positioned on
the wrong sides of the heart.
Rationale 3
This describes transposition of the great vessels.
Answer 3
false
Choice 4
Your babys heart doesnt circulate blood well because the left ventricle is
smaller and thinner than normal.
Rationale 4
This describes hypoplastic left heart syndrome.
Answer 4
false
Global Rationale
Meta 1
Cognitive Level:
Understanding
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Chapter 28_LO09_Q14

Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
admin
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:
LO09 - Identify the physical examination findings during the early newborn
period that would make the nurse suspect a congenital cardiac defect of
congestive heart failure.
Question 136583
Id:
136583
Type:
MCSA
Question
Title:
Difficulty
Level:
Calculator
:
Question Stem
The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is
experiencing tremors. What nursing action has the highest priority?
Stimulus
Answer
Choice 1
Rationale 1
Answer 1
Choice 2
Rationale 2
Answer 2
Choice 3
Rationale 3
Answer 3
Choice 4
Rationale 4
Answer 4
Obtain a bilirubin level.

Bilirubin level also might be necessary to monitor, but does not present with
tremors in the newborn.
false
Obtain a blood calcium level.
Tremors are the classical sign for hypocalcemia. Diabetic mothers tend to
have decreased serum magnesium levels at term. This could cause secondary
hypoparathyroidism in the infant.
true
Take the newborn's temperature.
Body temperature also might be necessary to monitor, but does not present
with tremors in the newborn.
false
Place a pulse oximeter on the newborn.
Oxygen saturation also might be necessary to monitor, but does not present
with tremors in the newborn.
false
Global Rationale
Meta 1
Cognitive Level:
Analyzing
Client Need:
Client Need Sub:

Nursing/Integrated
Concepts:
Content Area:
Content Area
Sub:
Meta 2
Clinical Domain:
Topical Category:
Key
Terms:
Strategy:
Meta 3
Reference:
Source Id:
Source Au Title Ed:
Source Usage:
Writer First Name:
Writer Last Name:
Royalty:
Stakes:
Special Handling:
Comments:
Meta 4
Learning Outcome 1:
27.3 Explain the impact of maternal diabetes mellitus on the newborn.
Learning Outcome 2:
Learning Outcome 3:
Learning Outcome 4:
Learning Outcome 5:
Learning Outcome 6:
Learning Outcome 7:
Learning Outcome 8:
Learning Outcome 9:
Standard 1:
Standard 2:
Standard 3:
Standard 4:
Standard 5:
Standard 6:

CH 27: Newborn at Risk

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CH 27: Newborn at Risk

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Question 139688

37-year-old G8 P2323, works in a chemical factory

23-year-old primip, low socioeconomic status, unmarried

16-year-old primip, began prenatal care at 30 weeks

28-year-old G2 P1001, history of gestational diabetes

Health Promotion and Maintenance

Client Need Sub:

Nursing Process: Assessment

Source Chapter Number:

Change from thin and underweight as a child to overweight or obese as

Poor fine motor coordination

Paralysis below the hips

Many infants with myelomeningocele will suffer life-long paralysis below

Although it may occur, disfiguration is not commonly associated with SGA

Health Promotion and Maintenance

Client Need Sub:

Nursing Process: Planning

Source Chapter Number:

LO02 - Compare the underlying etiologies of the physiologic complications

Monitor for feeding difficulties.

Assess for facial paralysis.

Monitor for signs of hyperglycemia.

SGA newborns are more prone to hypoglycemia.

Maintain a warm environment.

Hypothermia is a common complication of the SGA newborn; therefore, the

Client Need Sub:

Reduction of Risk Potential

Nursing Process: Implementation

Chapter 28_LO02 _Q03

Source Chapter Number:

LO02 - Compare the underlying etiologies of the physiologic complications

Recheck the blood sugar in four hours.

Begin an IV of 10% dextrose.

45mg/dl is considered a normal blood sugar reading for a neonate. No IV is

Feed the baby one ounce of formula.

Document the findings in the chart.

A blood sugar of 45 mg/dl is a normal finding; documentation is an

Health Promotion and Maintenance

Client Need Sub:

Nursing Process: Implementation

Chapter 28_LO03 _Q04

Source Chapter Number:

LO03 - Explain the impact of maternal diabetes mellitus on the newborn.

10 mg/kg/day of premature formula 24 kcal/oz.

20 mg/kg/day of premature formula 24 kcal/oz.

40 mg/kg/day of postdischarge formula 22 kcal/oz.

50 mg/kg/day of term formula 20 kcal/oz.

Client Need Sub:

Basic Care and Comfort

Nursing Process: Planning

Source Chapter Number:

LO05 - Discuss the physiologic and behavioral characteristics of the preterm

Babies can develop postmaturity syndrome, which increases their chances

This statement is correct.

Although this statement is partially true, meconium-stained amniotic fluid is

Although this statement is true, it is too vague. It is better to be specific and

The doctor wants to be proactive in preventing any problems with your

Although this is true, the answer is incomplete. The risk of postmaturity

Health Promotion and Maintenance

Client Need Sub:

Nursing Process: Implementation

Source Chapter Number:

LO04 - Compare the characteristics and potential complications that influence