NURSING 7304
Developmental Care of
the High Risk Neonate
and Family
Q & A w/ Rationales
2024
,1. A nurse is caring for a preterm infant who was born at 28
weeks gestation and weighs 1200 grams. The nurse
observes that the infant has episodes of apnea, bradycardia,
and cyanosis. What is the most appropriate nursing
intervention for this infant?
a) Stimulate the infant by rubbing the back or feet.
b) Administer oxygen via nasal cannula or mask.
c) Suction the infant's mouth and nose with a bulb syringe.
d) Place the infant in a prone position with the head
elevated.
*Answer: A. Stimulating the infant by rubbing the back or
feet is a simple and effective way to interrupt apnea and
bradycardia episodes in preterm infants. Oxygen
administration may be indicated if the infant does not
respond to stimulation, but it should be used with caution
as it can cause oxygen toxicity and retinopathy of
prematurity. Suctioning may be necessary if there is
excessive secretions, but it can also trigger apnea and
bradycardia by stimulating the vagus nerve. Prone
positioning may improve oxygenation and ventilation, but
it increases the risk of sudden infant death syndrome
(SIDS) and should only be used when the infant is closely
monitored.*
2. A nurse is teaching a mother how to provide kangaroo
care to her preterm infant who is stable but still requires
supplemental oxygen and intravenous fluids. Which of the
following statements by the mother indicates a need for
further teaching?
, a) "I will hold my baby skin-to-skin on my chest for at least
an hour at a time."
b) "I will feed my baby breast milk or formula during
kangaroo care if he shows signs of hunger."
c) "I will keep my baby warm by covering him with a
blanket and a hat."
d) "I will check my baby's temperature every 15 minutes
during kangaroo care."
*Answer: D. Checking the baby's temperature every 15
minutes during kangaroo care is unnecessary and
disruptive. Kangaroo care helps to maintain the baby's
temperature by providing direct skin contact with the
mother's body heat. The mother should check the baby's
temperature before and after kangaroo care, and adjust the
clothing and blankets as needed. The other statements are
correct and reflect the benefits of kangaroo care, such as
promoting bonding, breastfeeding, and growth.*
3. A nurse is assessing a term infant who was born to a
mother with diabetes mellitus. The nurse notes that the
infant has jitteriness, poor feeding, lethargy, and hypotonia.
What is the most likely cause of these signs and symptoms?
a) Hypoglycemia
b) Hyperglycemia
c) Hypocalcemia
d) Hyperbilirubinemia
*Answer: A. Hypoglycemia is a common complication in
infants of diabetic mothers, as they are exposed to high
levels of maternal glucose in utero, which stimulates their
own insulin production. After birth, when the glucose
Developmental Care of
the High Risk Neonate
and Family
Q & A w/ Rationales
2024
,1. A nurse is caring for a preterm infant who was born at 28
weeks gestation and weighs 1200 grams. The nurse
observes that the infant has episodes of apnea, bradycardia,
and cyanosis. What is the most appropriate nursing
intervention for this infant?
a) Stimulate the infant by rubbing the back or feet.
b) Administer oxygen via nasal cannula or mask.
c) Suction the infant's mouth and nose with a bulb syringe.
d) Place the infant in a prone position with the head
elevated.
*Answer: A. Stimulating the infant by rubbing the back or
feet is a simple and effective way to interrupt apnea and
bradycardia episodes in preterm infants. Oxygen
administration may be indicated if the infant does not
respond to stimulation, but it should be used with caution
as it can cause oxygen toxicity and retinopathy of
prematurity. Suctioning may be necessary if there is
excessive secretions, but it can also trigger apnea and
bradycardia by stimulating the vagus nerve. Prone
positioning may improve oxygenation and ventilation, but
it increases the risk of sudden infant death syndrome
(SIDS) and should only be used when the infant is closely
monitored.*
2. A nurse is teaching a mother how to provide kangaroo
care to her preterm infant who is stable but still requires
supplemental oxygen and intravenous fluids. Which of the
following statements by the mother indicates a need for
further teaching?
, a) "I will hold my baby skin-to-skin on my chest for at least
an hour at a time."
b) "I will feed my baby breast milk or formula during
kangaroo care if he shows signs of hunger."
c) "I will keep my baby warm by covering him with a
blanket and a hat."
d) "I will check my baby's temperature every 15 minutes
during kangaroo care."
*Answer: D. Checking the baby's temperature every 15
minutes during kangaroo care is unnecessary and
disruptive. Kangaroo care helps to maintain the baby's
temperature by providing direct skin contact with the
mother's body heat. The mother should check the baby's
temperature before and after kangaroo care, and adjust the
clothing and blankets as needed. The other statements are
correct and reflect the benefits of kangaroo care, such as
promoting bonding, breastfeeding, and growth.*
3. A nurse is assessing a term infant who was born to a
mother with diabetes mellitus. The nurse notes that the
infant has jitteriness, poor feeding, lethargy, and hypotonia.
What is the most likely cause of these signs and symptoms?
a) Hypoglycemia
b) Hyperglycemia
c) Hypocalcemia
d) Hyperbilirubinemia
*Answer: A. Hypoglycemia is a common complication in
infants of diabetic mothers, as they are exposed to high
levels of maternal glucose in utero, which stimulates their
own insulin production. After birth, when the glucose
