Chapter 35: Acquired Problems of the Newborn
MULTIPLE CHOICE
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 lb, 6 oz). What is the nurse’s first
priority?
a. Leave the infant in the room with the mother.
b. Immediately take the infant to the nursery.
c. Perform a gestational age assessment to determine whether the infant is large for
gestational age.
d. Frequently monitor blood glucose levels, and closely observe the infant for signs
of hypoglycemia.
ANS: D
Regardless of gestational age, this infant is macrosomic (defined as fetal weight more than
4000 g) and is at high risk for hypoglycemia, which affects many macrosomic infants.
Blood glucose levels should be frequently monitored, and the infant should be closely
observed for signs of hypoglycemia. Close observation can be achieved in the mother’s
room with nursing interventions. However, depending on the condition of the infant,
observation may be more appropriate in the nursery.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
NURSINGTB.COM
2. A 3.8-kg infant was vaginally delivered at 39 weeks after a 30-minute second stage. A
nuchal cord was found at delivery. After birth, the infant is noted to have petechiae over the
face and upper back. Which information regarding petechiae is most accurate and should be
provided to the parents?
a. Are benign if they disappear within 48 hours of birth
b. Result from increased blood volume
c. Should always be further investigated
d. Usually occur with a forceps-assisted delivery
ANS: A
Petechiae, or pinpoint hemorrhagic areas, acquired during childbirth may extend over the
upper portion of the trunk and face. These lesions are benign if they disappear within 2 days
of childbirth and no new lesions appear. Petechiae may result from decreased platelet
formation. In this situation, the presence of petechiae is most likely a soft-tissue injury
resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days,
alarming the family is not necessary. Petechiae usually occur with a breech presentation
vaginal birth.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
,3. What information regarding a fractured clavicle is most important for the nurse to take into
consideration when planning the infant’s care?
a. Prone positioning facilitates bone alignment.
b. No special treatment is necessary.
c. Parents should be taught range-of-motion exercises.
d. The shoulder should be immobilized with a splint.
ANS: B
Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted
treatment for a fractured clavicle exists. Movement should be limited, and the infant should
be gently handled. Performing range-of-motion exercises on the infant is not necessary. A
fractured clavicle does not require immobilization with a splint.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing?
a. Iron deficiency anemia
b. Hyponatremia
c. Respiratory distress syndrome
d. Sepsis
ANS: C
IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress
syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy,
hyperbilirubinemia, and polycythemia. IDMs are not at risk for anemia, hyponatremia, or
sepsis.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
5. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A
cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth
is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6
and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal
history, what is the most likely cause of this newborn’s distress?
a. Hypoglycemia
b. Phrenic nerve injury
c. Respiratory distress syndrome
d. Sepsis
ANS: D
The prolonged rupture of membranes and the tachypnea (before and after birth) suggest
sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to
noninfectious problems such as anemia and hypoglycemia. Phrenic nerve injury is usually
the result of traction on the neck and arm during childbirth and is not applicable to this
situation. The earliest signs of sepsis are characterized by lack of specificity (e.g., lethargy,
poor feeding, irritability), not respiratory distress syndrome.
PTS: 1 DIF: Cognitive Level: Understand
, TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care.
After birth, her infant is noted to be small for gestational age with small eyes and a thin
upper lip. The infant also is microcephalic. Based on her infant’s physical findings, this
woman should be questioned about her use of which substance during pregnancy?
a. Alcohol
b. Cocaine
c. Heroin
d. Marijuana
ANS: A
The description of the infant suggests fetal alcohol syndrome, which is consistent with
maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system
malformations have been associated with maternal cocaine ingestions. Heroin use in
pregnancy frequently results in intrauterine growth restriction (IUGR). The infant may have
a shrill cry and sleep-cycle disturbances and may exhibit with poor feeding, tachypnea,
vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher
incidence of meconium staining in infants born of mothers who used marijuana during
pregnancy.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
7. For an infant experiencing symptoms of drug withdrawal, which intervention should be
included in the plan of care?
a. Administering chloral hNyU drR eI
atS rG
foN daB
s eT ti.
onC OM
b. Feeding every 4 to 6 hours to allow extra rest between feedings
c. Snugly swaddling the infant and tightly holding the baby
d. Playing soft music during feeding
ANS: C
The infant should be snugly wrapped to reduce self-stimulation behaviors and to protect the
skin from abrasions. Phenobarbital or diazepam may be administered to decrease central
nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and
burped well to diminish aspiration and maintain hydration. The infant should not be
stimulated (such as with music), because stimulation will increase activity and potentially
increase CNS irritability.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
8. Human immunodeficiency virus (HIV) may be transmitted perinatally or during the
postpartum period. Which statement regarding the method of transmission is most accurate?
a. Only in the third trimester from the maternal circulation
b. From the use of unsterile instruments
c. Only through the ingestion of amniotic fluid
d. Through the ingestion of breast milk from an infected mother
ANS: D
MULTIPLE CHOICE
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 lb, 6 oz). What is the nurse’s first
priority?
a. Leave the infant in the room with the mother.
b. Immediately take the infant to the nursery.
c. Perform a gestational age assessment to determine whether the infant is large for
gestational age.
d. Frequently monitor blood glucose levels, and closely observe the infant for signs
of hypoglycemia.
ANS: D
Regardless of gestational age, this infant is macrosomic (defined as fetal weight more than
4000 g) and is at high risk for hypoglycemia, which affects many macrosomic infants.
Blood glucose levels should be frequently monitored, and the infant should be closely
observed for signs of hypoglycemia. Close observation can be achieved in the mother’s
room with nursing interventions. However, depending on the condition of the infant,
observation may be more appropriate in the nursery.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
NURSINGTB.COM
2. A 3.8-kg infant was vaginally delivered at 39 weeks after a 30-minute second stage. A
nuchal cord was found at delivery. After birth, the infant is noted to have petechiae over the
face and upper back. Which information regarding petechiae is most accurate and should be
provided to the parents?
a. Are benign if they disappear within 48 hours of birth
b. Result from increased blood volume
c. Should always be further investigated
d. Usually occur with a forceps-assisted delivery
ANS: A
Petechiae, or pinpoint hemorrhagic areas, acquired during childbirth may extend over the
upper portion of the trunk and face. These lesions are benign if they disappear within 2 days
of childbirth and no new lesions appear. Petechiae may result from decreased platelet
formation. In this situation, the presence of petechiae is most likely a soft-tissue injury
resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days,
alarming the family is not necessary. Petechiae usually occur with a breech presentation
vaginal birth.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
,3. What information regarding a fractured clavicle is most important for the nurse to take into
consideration when planning the infant’s care?
a. Prone positioning facilitates bone alignment.
b. No special treatment is necessary.
c. Parents should be taught range-of-motion exercises.
d. The shoulder should be immobilized with a splint.
ANS: B
Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted
treatment for a fractured clavicle exists. Movement should be limited, and the infant should
be gently handled. Performing range-of-motion exercises on the infant is not necessary. A
fractured clavicle does not require immobilization with a splint.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. Which conditions are infants of diabetic mothers (IDMs) at a higher risk for developing?
a. Iron deficiency anemia
b. Hyponatremia
c. Respiratory distress syndrome
d. Sepsis
ANS: C
IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress
syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy,
hyperbilirubinemia, and polycythemia. IDMs are not at risk for anemia, hyponatremia, or
sepsis.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
5. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A
cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth
is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6
and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal
history, what is the most likely cause of this newborn’s distress?
a. Hypoglycemia
b. Phrenic nerve injury
c. Respiratory distress syndrome
d. Sepsis
ANS: D
The prolonged rupture of membranes and the tachypnea (before and after birth) suggest
sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to
noninfectious problems such as anemia and hypoglycemia. Phrenic nerve injury is usually
the result of traction on the neck and arm during childbirth and is not applicable to this
situation. The earliest signs of sepsis are characterized by lack of specificity (e.g., lethargy,
poor feeding, irritability), not respiratory distress syndrome.
PTS: 1 DIF: Cognitive Level: Understand
, TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care.
After birth, her infant is noted to be small for gestational age with small eyes and a thin
upper lip. The infant also is microcephalic. Based on her infant’s physical findings, this
woman should be questioned about her use of which substance during pregnancy?
a. Alcohol
b. Cocaine
c. Heroin
d. Marijuana
ANS: A
The description of the infant suggests fetal alcohol syndrome, which is consistent with
maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system
malformations have been associated with maternal cocaine ingestions. Heroin use in
pregnancy frequently results in intrauterine growth restriction (IUGR). The infant may have
a shrill cry and sleep-cycle disturbances and may exhibit with poor feeding, tachypnea,
vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher
incidence of meconium staining in infants born of mothers who used marijuana during
pregnancy.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
7. For an infant experiencing symptoms of drug withdrawal, which intervention should be
included in the plan of care?
a. Administering chloral hNyU drR eI
atS rG
foN daB
s eT ti.
onC OM
b. Feeding every 4 to 6 hours to allow extra rest between feedings
c. Snugly swaddling the infant and tightly holding the baby
d. Playing soft music during feeding
ANS: C
The infant should be snugly wrapped to reduce self-stimulation behaviors and to protect the
skin from abrasions. Phenobarbital or diazepam may be administered to decrease central
nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and
burped well to diminish aspiration and maintain hydration. The infant should not be
stimulated (such as with music), because stimulation will increase activity and potentially
increase CNS irritability.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
8. Human immunodeficiency virus (HIV) may be transmitted perinatally or during the
postpartum period. Which statement regarding the method of transmission is most accurate?
a. Only in the third trimester from the maternal circulation
b. From the use of unsterile instruments
c. Only through the ingestion of amniotic fluid
d. Through the ingestion of breast milk from an infected mother
ANS: D
