Test #5 Study Guide
ATI Chapter 27: Assessment and Management of Newborn Complications
1. A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the
nurse what to expect because the baby is postmature. Which of the following statements should
the nurse make?
A. “Your baby will have excess body fat.”
B. “Your baby will have flat areola without breast buds.”
C. “Your baby’s heels will easily move to his ears.”
D. “Your baby’s skin will have a leathery appearance.”
Rationale:
A. Excess body fat is seen in a newborn who is macrosomic.
B. Flat areolas without breast buds are seen in a newborn who is preterm.
C. Heels that are movable fully to the ears are seen in a newborn who is preterm.
D. CORRECT: Leathery, cracked, and wrinkled skin is seen in a newborn who is postmature due
to placental insufficiency.
2. A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy.
Which of the following is the priority finding in the newborn?
A. Conjunctivitis
B. Bronze skin discoloration
C. Sunken fontanels
D. Maculopapular skin rash
Rationale:
A. Conjunctivitis is an important finding, but it is not the priority.
B. Bronze skin discoloration is an important finding, but it is not the priority.
C. CORRECT: Using the safety and risk reduction framework, sunken fontanels is the priority
finding. Infants receiving phototherapy are at risk for dehydration from loose stools due to
increased bilirubin excretion.
D. Maculopapular skin rash is an important finding, but it is not the priority.
3. A nurse is called to the birthing room to assist with the assessment of a newborn who was born
at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. Which of the following are
expected findings in this newborn? (Select all that apply.)
,A. Lanugo
B. Long nails
C. Weak grasp reflex
D. Translucent skin
E. Plump face
Rationale:
A. CORRECT: Characteristics of a preterm newborn include the presence of abundant lanugo.
B. Long nails are a finding in a newborn who is postmature.
C. CORRECT: A weak grasp reflex is characteristic of a preterm newborn.
D. CORRECT: Skin that is thin, smooth, shiny, and translucent is a finding in a preterm
newborn.
E. A plump face would be observed in a newborn who is macrosomic.
4. A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which
of the following should the nurse monitor to evaluate the newborn’s condition following
administration of synthetic surfactant?
A. Oxygen saturation
B. Body temperature
C. Serum bilirubin
D. Heart rate
Rationale:
A. CORRECT: Surfactant stabilizes the alveoli and helps increase oxygen saturation.
B. Surfactant administration has no direct effect on body temperature.
C. Surfactant administration has no direct effect on bilirubin levels.
D. Surfactant administration has no direct effect on heart rate.
5. A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the
following statements by the newly licensed nurse indicate understanding of the teaching?
A. “The newborn will have decreased muscle tone.”
B. “The newborn will have a continuous high‑pitched cry.”
C. “The newborn will sleep for 2 to 3 hours after a feeding.”
D. “The newborn will have mild tremors when disturbed.”
,Rationale:
A. Increased muscle tone is seen in a newborn who has neonatal abstinence syndrome.
B. CORRECT: A continuous high‑pitched cry is often an indication of CNS disturbances in a
newborn who has neonatal abstinence syndrome.
C. A newborn who has neonatal abstinence syndrome can have sleep pattern disturbances and
would have difficulty sleeping for 2 to 3 hr after feeding.
D. A newborn who has neonatal abstinence syndrome often has moderate to severe tremors when
undisturbed. Most newborns exhibit mild tremors when disturbed.
Chapter 30: The Newborn at Risk: Conditions Present at Birth
1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39
mg/dL. What should the nurse include in the plan of care for this newborn?
A) Offer early feedings with formula or breast milk.
B) Provide glucose water exclusively.
C) Evaluate blood glucose levels at 12 hours after birth.
D) Assess for hyperthermia.
Answer: A
Explanation:
A) IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or
breast milk (colostrum).
B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion
of glucose will be necessary.
C) Blood glucose determinations should be performed by heel stick hourly during the first 4
hours after birth and at 4-hour intervals until the risk period (about 48 hours) has passed.
D) Hypothermia is a potential problem for the SGA newborn due to decreased brown fat stores
and minimal subcutaneous tissues.
Page Ref: 758
2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is
most likely to have a newborn at risk for mortality or morbidity?
A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical
factory
B) 23-year-old of low socioeconomic status, unmarried
C) 16-year-old who began prenatal care at 30 weeks
, D) 28-year-old with a history of gestational diabetes
Answer: A
Explanation:
A) This client 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.
B) The main risk factor for this client is her low socioeconomic status.
C) This client has two risk factors: young age and late onset of prenatal care.
D) This client's only risk factor is the history of gestational diabetes.
Page Ref: 754
3) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces).
The head circumference and length are in the 25th percentile. What statement would the nurse
expect to find in the chart?
A) Preterm appropriate for gestational age, symmetrical IUGR
B) Term small for gestational age, symmetrical IUGR
C) Preterm small for gestational age, asymmetrical IUGR
D) Preterm appropriate for gestational age, asymmetrical IUGR
Answer: C
Explanation:
A) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical
IUGR.
B) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical
IUGR.
C) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
is small for gestational age. Head circumference and length between the 10th and 90th
percentiles indicate asymmetrical IUGR.
D) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
is considered small for gestational age.
Page Ref: 755
4) A 38-week newborn is found to be small for gestational age (SGA). Which nursing
intervention should be included in the care of this newborn?
A) Monitor for feeding difficulties.
ATI Chapter 27: Assessment and Management of Newborn Complications
1. A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the
nurse what to expect because the baby is postmature. Which of the following statements should
the nurse make?
A. “Your baby will have excess body fat.”
B. “Your baby will have flat areola without breast buds.”
C. “Your baby’s heels will easily move to his ears.”
D. “Your baby’s skin will have a leathery appearance.”
Rationale:
A. Excess body fat is seen in a newborn who is macrosomic.
B. Flat areolas without breast buds are seen in a newborn who is preterm.
C. Heels that are movable fully to the ears are seen in a newborn who is preterm.
D. CORRECT: Leathery, cracked, and wrinkled skin is seen in a newborn who is postmature due
to placental insufficiency.
2. A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy.
Which of the following is the priority finding in the newborn?
A. Conjunctivitis
B. Bronze skin discoloration
C. Sunken fontanels
D. Maculopapular skin rash
Rationale:
A. Conjunctivitis is an important finding, but it is not the priority.
B. Bronze skin discoloration is an important finding, but it is not the priority.
C. CORRECT: Using the safety and risk reduction framework, sunken fontanels is the priority
finding. Infants receiving phototherapy are at risk for dehydration from loose stools due to
increased bilirubin excretion.
D. Maculopapular skin rash is an important finding, but it is not the priority.
3. A nurse is called to the birthing room to assist with the assessment of a newborn who was born
at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. Which of the following are
expected findings in this newborn? (Select all that apply.)
,A. Lanugo
B. Long nails
C. Weak grasp reflex
D. Translucent skin
E. Plump face
Rationale:
A. CORRECT: Characteristics of a preterm newborn include the presence of abundant lanugo.
B. Long nails are a finding in a newborn who is postmature.
C. CORRECT: A weak grasp reflex is characteristic of a preterm newborn.
D. CORRECT: Skin that is thin, smooth, shiny, and translucent is a finding in a preterm
newborn.
E. A plump face would be observed in a newborn who is macrosomic.
4. A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which
of the following should the nurse monitor to evaluate the newborn’s condition following
administration of synthetic surfactant?
A. Oxygen saturation
B. Body temperature
C. Serum bilirubin
D. Heart rate
Rationale:
A. CORRECT: Surfactant stabilizes the alveoli and helps increase oxygen saturation.
B. Surfactant administration has no direct effect on body temperature.
C. Surfactant administration has no direct effect on bilirubin levels.
D. Surfactant administration has no direct effect on heart rate.
5. A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the
following statements by the newly licensed nurse indicate understanding of the teaching?
A. “The newborn will have decreased muscle tone.”
B. “The newborn will have a continuous high‑pitched cry.”
C. “The newborn will sleep for 2 to 3 hours after a feeding.”
D. “The newborn will have mild tremors when disturbed.”
,Rationale:
A. Increased muscle tone is seen in a newborn who has neonatal abstinence syndrome.
B. CORRECT: A continuous high‑pitched cry is often an indication of CNS disturbances in a
newborn who has neonatal abstinence syndrome.
C. A newborn who has neonatal abstinence syndrome can have sleep pattern disturbances and
would have difficulty sleeping for 2 to 3 hr after feeding.
D. A newborn who has neonatal abstinence syndrome often has moderate to severe tremors when
undisturbed. Most newborns exhibit mild tremors when disturbed.
Chapter 30: The Newborn at Risk: Conditions Present at Birth
1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39
mg/dL. What should the nurse include in the plan of care for this newborn?
A) Offer early feedings with formula or breast milk.
B) Provide glucose water exclusively.
C) Evaluate blood glucose levels at 12 hours after birth.
D) Assess for hyperthermia.
Answer: A
Explanation:
A) IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or
breast milk (colostrum).
B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion
of glucose will be necessary.
C) Blood glucose determinations should be performed by heel stick hourly during the first 4
hours after birth and at 4-hour intervals until the risk period (about 48 hours) has passed.
D) Hypothermia is a potential problem for the SGA newborn due to decreased brown fat stores
and minimal subcutaneous tissues.
Page Ref: 758
2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is
most likely to have a newborn at risk for mortality or morbidity?
A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical
factory
B) 23-year-old of low socioeconomic status, unmarried
C) 16-year-old who began prenatal care at 30 weeks
, D) 28-year-old with a history of gestational diabetes
Answer: A
Explanation:
A) This client 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.
B) The main risk factor for this client is her low socioeconomic status.
C) This client has two risk factors: young age and late onset of prenatal care.
D) This client's only risk factor is the history of gestational diabetes.
Page Ref: 754
3) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces).
The head circumference and length are in the 25th percentile. What statement would the nurse
expect to find in the chart?
A) Preterm appropriate for gestational age, symmetrical IUGR
B) Term small for gestational age, symmetrical IUGR
C) Preterm small for gestational age, asymmetrical IUGR
D) Preterm appropriate for gestational age, asymmetrical IUGR
Answer: C
Explanation:
A) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical
IUGR.
B) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical
IUGR.
C) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
is small for gestational age. Head circumference and length between the 10th and 90th
percentiles indicate asymmetrical IUGR.
D) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
is considered small for gestational age.
Page Ref: 755
4) A 38-week newborn is found to be small for gestational age (SGA). Which nursing
intervention should be included in the care of this newborn?
A) Monitor for feeding difficulties.
