Chapter 34: Nursing Care of the High Risk Newborn Lowdermilk: Maternity & Women’s Health Care, 11th Edition

TEST BANK FOR MATERNITY & WOMEN’S HEALTH CARE 11TH EDITION BY LOWDERMILK Chapter 34: Nursing Care of the High Risk Newborn Lowdermilk: Maternity & Women’s Health Care, 11th Edition MULTIPLE CHOICE 1. An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia? a. 67 mm Hg b. 89 mm Hg c. 45 mm Hg d. 73 mm Hg CORRECT ANSWER: C The laboratory value of PaO2 of 45 mm Hg is below the range for a normal neonate and indicates hypoxia in this infant. The normal range for PaO2 is 60 to 80 mm Hg; therefore, PaO2 levels of 67 and 73 mm Hg fall within the normal range, and a PaO2 of 89 mm Hg is higher than the normal range. DIF: Cognitive Level: Understand REF: p. 837 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 2. On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? a. ―Parents are not allowed to hold their infants who are dependent on oxygen.‖ b. ―You may only hold your baby‘s hand during the feeding.‖ c. ―Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don‘t think you should hold the baby.‖ d. ―You may hold your baby during the feeding.‖ CORRECT ANSWER: D Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions. DIF: Cognitive Level: Apply REF: p. 834 TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 3. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? a. ―Surfactant improves the ability of your baby‘s lungs to exchange oxygen and carbon dioxide.‖ b. ―The drug keeps your baby from requiring too much sedation.‖ c. ―Surfactant is used to reduce episodes of periodic apnea.‖ d. ―Your baby needs this medication to fight a possible respiratory tract infection.‖ CORRECT ANSWER: A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection. DIF: Cognitive Level: Apply REF: p. 826 TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 4. An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a. Rapid bolusing of the entire amount in 15 minutes b. Warm cloths to the abdomen for the first 10 minutes c. Slow, small, warm bolus feedings over 30 minutes d. Cold, medium bolus feedings over 20 minutes CORRECT ANSWER: C Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions. DIF: Cognitive Level: Apply REF: p. 830 TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 5. A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with ―ineffective coping, related to‖? a. Severe immaturity b. Environmental stress c. Physiologic distress d. Behavioral responses CORRECT ANSWER: B ―Ineffective coping, related to environmental stress‖ is the most appropriate nursing diagnosis for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must closely monitor the environment for sources of overstimulation. Although the infant may be severely immature in this case, she is responding to environmental stress. Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system. The infant‘s behavioral response to the environmental stress is crying. The appropriate nursing diagnosis reflects the cause of this response. DIF: Cognitive Level: Apply REF: pp. 831-832 TOP: Nursing Process: Diagnosis MSC: Client Needs: Safe and Effective Care Environment 6. Which clinical findings would alert the nurse that the neonate is expressing pain? a. Low-pitched crying; tachycardia; eyelids open wide b. Cry face; flaccid limbs; closed mouth c. High-pitched, shrill cry; withdrawal; change in heart rate d. Cry face; eyes squeezed; increase in blood pressure CORRECT ANSWER: D Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies. DIF: Cognitive Level: Understand REF: p. 840 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborn‘s parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurse‘s most appropriate action? a. Wait quietly at the newborn‘s bedside until the parents come closer. b. Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn. c. Leave the parents at the bedside while they are visiting so that they have some privacy. d. Tell the parents only about the newborn‘s physical condition and caution them to avoid touching their baby. CORRECT ANSWER: B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant‘s condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant‘s appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful. DIF: Cognitive Level: Apply REF: p. 834 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity