Maternal Child Nursing Care - Chapter 25: The
High-Risk Newborn Exam Question and Answer
1. A macrosomic infant is born after a difficult forceps-assisted
delivery. After stabilization the infant is weighed, and the birth
weight is 4550 g (9 lbs, 6 ounces). The nurse's most appropriate
action is to correct answer:
a. leave the infant in the room with the mother.
b. take the infant immediately to the nursery.
c. perform a gestational age assessment to determine whether
the infant is large for gestational age.
d. monitor blood glucose levels frequently and observe closely for
signs of hypoglycemia. correct answer: ANS correct answer: D
This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels
should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia.
Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus.
Regardless of gestational age, this infant is macrosomic.
2. Infants of mothers with diabetes (IDMs) are at higher risk for
developing correct answer:
a. anemia.
b. hyponatremia.
c. respiratory distress syndrome.
d. sepsis. correct answer: ANS correct answer: C
IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome,
hypoglycemia, hypocal-cemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia.
They are not at risk for anemia, hyponatremia, or sepsis.
3. An infant was born 2 hours ago at 37 weeks of gestation and
weighing 4.1 kg. The infant appears chubby with a flushed
complexion and is very tremulous. The tremors are most likely
,the result of correct answer:
a. birth injury.
b. hypocalcemia.
c. hypoglycemia.
d. seizures. correct answer: ANS correct answer: C
,Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea,
tachypnea, and cyanosis.
4. When assessing the preterm infant the nurse understands that
compared with the term infant, the preterm infant has correct
answer:
a. few blood vessels visible through the skin.
b. more subcutaneous fat.
c. well-developed flexor muscles.
d. greater surface area in proportion to weight. correct answer: ANS
correct answer: D
Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-
developed muscles are indications of a more mature infant.
5. On day 3 of life, a newborn continues to require 100% oxygen by
nasal cannu-la. The parents ask whether they can hold their infant
during his next gavage feeding. Given that this newborn is
physiologically stable, what response would the nurse give?
a. "Parents are not allowed to hold infants who depend on oxygen."
b. "You may hold only your baby's hand during the feeding."
c. "Feedings cause more physiologic stress, so the baby must be
closely moni-tored. Therefore, I don't think you should hold the
baby."
d. "You may hold your baby during the feeding." correct answer: ANS
correct answer: D
"You may hold your baby during the feeding" is an accurate statement. Parental interaction via holding is
encouraged during gavage feedings so that the infant will associate the feeding with positive
interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions.
The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with
positive interactions. Some parents like to do kangaroo care while gavage feeding their infant.
Swaddling or kangaroo care during feedings provides positive interactions for the infant.
, 6. A premature infant with respiratory distress syndrome receives
artificial sur-factant. How would the nurse explain surfactant
therapy to the parents?
a."Surfactant improves the ability of your baby's lungs to exchange
oxygen and
High-Risk Newborn Exam Question and Answer
1. A macrosomic infant is born after a difficult forceps-assisted
delivery. After stabilization the infant is weighed, and the birth
weight is 4550 g (9 lbs, 6 ounces). The nurse's most appropriate
action is to correct answer:
a. leave the infant in the room with the mother.
b. take the infant immediately to the nursery.
c. perform a gestational age assessment to determine whether
the infant is large for gestational age.
d. monitor blood glucose levels frequently and observe closely for
signs of hypoglycemia. correct answer: ANS correct answer: D
This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels
should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia.
Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus.
Regardless of gestational age, this infant is macrosomic.
2. Infants of mothers with diabetes (IDMs) are at higher risk for
developing correct answer:
a. anemia.
b. hyponatremia.
c. respiratory distress syndrome.
d. sepsis. correct answer: ANS correct answer: C
IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome,
hypoglycemia, hypocal-cemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia.
They are not at risk for anemia, hyponatremia, or sepsis.
3. An infant was born 2 hours ago at 37 weeks of gestation and
weighing 4.1 kg. The infant appears chubby with a flushed
complexion and is very tremulous. The tremors are most likely
,the result of correct answer:
a. birth injury.
b. hypocalcemia.
c. hypoglycemia.
d. seizures. correct answer: ANS correct answer: C
,Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea,
tachypnea, and cyanosis.
4. When assessing the preterm infant the nurse understands that
compared with the term infant, the preterm infant has correct
answer:
a. few blood vessels visible through the skin.
b. more subcutaneous fat.
c. well-developed flexor muscles.
d. greater surface area in proportion to weight. correct answer: ANS
correct answer: D
Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-
developed muscles are indications of a more mature infant.
5. On day 3 of life, a newborn continues to require 100% oxygen by
nasal cannu-la. The parents ask whether they can hold their infant
during his next gavage feeding. Given that this newborn is
physiologically stable, what response would the nurse give?
a. "Parents are not allowed to hold infants who depend on oxygen."
b. "You may hold only your baby's hand during the feeding."
c. "Feedings cause more physiologic stress, so the baby must be
closely moni-tored. Therefore, I don't think you should hold the
baby."
d. "You may hold your baby during the feeding." correct answer: ANS
correct answer: D
"You may hold your baby during the feeding" is an accurate statement. Parental interaction via holding is
encouraged during gavage feedings so that the infant will associate the feeding with positive
interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions.
The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with
positive interactions. Some parents like to do kangaroo care while gavage feeding their infant.
Swaddling or kangaroo care during feedings provides positive interactions for the infant.
, 6. A premature infant with respiratory distress syndrome receives
artificial sur-factant. How would the nurse explain surfactant
therapy to the parents?
a."Surfactant improves the ability of your baby's lungs to exchange
oxygen and
