Chapter 34: Nursing Care of the High Risk Newborn
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
ANS: 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.
PTS: 1 DIF: Cognitive Level: Understand
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 physiologicallyNstUabRleS, I
wNhaGt T
reB
sp.oC eM
nsO 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.”
ANS: 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.
PTS: 1 DIF: Cognitive Level: Apply
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.”
ANS: 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.
PTS: 1 DIF: Cognitive Level: Apply
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
ANS: C NURSINGTB.COM
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.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
5. 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.
ANS: 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.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
6. An infant is being discharged from the NICU after 70 days of hospitalization. The infant
was born at 30 weeks of gestation with several conditions associated with prematurity,
including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity
(ROP), requiring surgical treatment. During discharge teaching, the infant’s mother asks the
nurse if her baby will meet developmental milestones on time, as did her son who was born
at term. What is the nurse’s most appropriate response?
a. “Your baby will develop exactly like your first child.”
b. “Your baby does not appear to have any problems at this time.”
c. “Your baby will need to be corrected for prematurity.”
d. “Your baby will need to be followed very closely.”
ANS: C NURSINGTB.COM
The age of a preterm newborn is corrected by adding the gestational age and the postnatal
age. The infant’s responses are accordingly evaluated against the norm expected for the
corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can
be expected to be doing what a 40-week-old infant would be doing. Although predicting
with complete accuracy the growth and development potential of each preterm infant is
impossible, certain measurable factors predict normal growth and development. The preterm
infant experiences catch-up body growth during the first 2 to 3 years of life. Development
needs to be evaluated over time. The growth and developmental milestones are corrected for
gestational age until the child is approximately years old.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure
dates. A nonstress test (NST) in the obstetrician’s office revealed a nonreactive tracing. On
artificial rupture of membranes, thick meconium-stained fluid was noted. What should the
nurse caring for the infant after birth anticipate?
a. Meconium aspiration, hypoglycemia, and dry, cracked skin
b. Excessive vernix caseosa covering the skin, lethargy, and RDS
c. Golden yellow to green-stained skin and nails, absence of scalp hair, and an
increased amount of subcutaneous fat
d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance
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
ANS: 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.
PTS: 1 DIF: Cognitive Level: Understand
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 physiologicallyNstUabRleS, I
wNhaGt T
reB
sp.oC eM
nsO 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.”
ANS: 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.
PTS: 1 DIF: Cognitive Level: Apply
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.”
ANS: 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.
PTS: 1 DIF: Cognitive Level: Apply
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
ANS: C NURSINGTB.COM
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.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
5. 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.
ANS: 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.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
6. An infant is being discharged from the NICU after 70 days of hospitalization. The infant
was born at 30 weeks of gestation with several conditions associated with prematurity,
including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity
(ROP), requiring surgical treatment. During discharge teaching, the infant’s mother asks the
nurse if her baby will meet developmental milestones on time, as did her son who was born
at term. What is the nurse’s most appropriate response?
a. “Your baby will develop exactly like your first child.”
b. “Your baby does not appear to have any problems at this time.”
c. “Your baby will need to be corrected for prematurity.”
d. “Your baby will need to be followed very closely.”
ANS: C NURSINGTB.COM
The age of a preterm newborn is corrected by adding the gestational age and the postnatal
age. The infant’s responses are accordingly evaluated against the norm expected for the
corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can
be expected to be doing what a 40-week-old infant would be doing. Although predicting
with complete accuracy the growth and development potential of each preterm infant is
impossible, certain measurable factors predict normal growth and development. The preterm
infant experiences catch-up body growth during the first 2 to 3 years of life. Development
needs to be evaluated over time. The growth and developmental milestones are corrected for
gestational age until the child is approximately years old.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure
dates. A nonstress test (NST) in the obstetrician’s office revealed a nonreactive tracing. On
artificial rupture of membranes, thick meconium-stained fluid was noted. What should the
nurse caring for the infant after birth anticipate?
a. Meconium aspiration, hypoglycemia, and dry, cracked skin
b. Excessive vernix caseosa covering the skin, lethargy, and RDS
c. Golden yellow to green-stained skin and nails, absence of scalp hair, and an
increased amount of subcutaneous fat
d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance
