Chapter 31 The Newborn at Risk: Birth-Related Stressors
1) The nurse prepares to admit to the nursery a newborn whose mother had
meconium-stained amniotic fluid. The nurse knows this newborn might require
which of the following?
1. Initial resuscitation
2. Vigorous stimulation at birth
3. Phototherapy immediately
4. An initial feeding of iron-enriched formula
Answer: 1
Explanation: 1. The presence of meconium in the amniotic fluid indicates that
the fetus may be suffering from asphyxia. Meconium-stained newborns or
newborns who have aspirated particulate meconium often have respiratory
depression at birth and require resuscitation to establish adequate respiratory
effort.
Page Ref: 826
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing
interventions as appropriate for managing the acute and chronic care of patients
and promoting health across the lifespan. | NLN Competencies: Quality and
Safety: Communicate potential risk factors and actual errors. |
,Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2 Differentiate, based on clinical manifestations, among the
various types of respiratory distress (respiratory distress syndrome, transient
tachypnea of the newborn, meconium aspiration syndrome, and persistent
pulmonary hypertension) in the newborn and each types related nursing care.
MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their
associated nursing care.
1
Copyright 2016 Pearson Education, Inc.
2) A laboring mother has recurrent late decelerations. At birth, the infant has
a heart rate of 100, is not breathing, and is limp and bluish in color. What
nursing action is best?
1. Begin chest compressions.
2. Begin direct tracheal suctioning.
3. Begin bag-and-mask ventilation.
4. Obtain a blood pressure reading.
Answer: 3
Explanation: 3. Most newborns can be effectively resuscitated by bag-and-
mask ventilation.
Page Ref: 814
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing
interventions as appropriate for managing the acute and chronic care of patients
and promoting health across the lifespan. | NLN Competencies: Quality and
Safety: Communicate potential risk factors and actual errors. |
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1 Describe how to identify infants in need of
resuscitation and the appropriate method of resuscitation based on the
,prenatal/labor record and observable physiologic indicators.
MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their
associated nursing care.
2
Copyright 2016 Pearson Education, Inc.
3) Which fetal/neonatal risk factors would lead the nurse to anticipate a
potential need to resuscitate a newborn?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Nonreassuring fetal heart rate pattern/sustained bradycardia
2. Fetal scalp/capillary blood sample pH greater than 7.25
3. History of meconium in amniotic fluid
4. Prematurity
5. Significant intrapartum bleeding
Answer: 1, 3, 4, 5
Explanation: 1. Nonreassuring fetal heart rate pattern/sustained bradycardia
would be considered a potential need to resuscitate a newborn.
3. History of meconium in amniotic fluid would be considered a potential
need to resuscitate a newborn.
4. Prematurity would be considered a potential need to resuscitate a newborn.
5. Significant intrapartum bleeding would be considered a potential need to
resuscitate a newborn.
Page Ref: 812
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
, developmentally and culturally appropriate approaches. | NLN Competencies:
Relationship-Centered Care: Factors that contribute to or threaten health. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1 Describe how to identify infants in need of
resuscitation and the appropriate method of resuscitation based on the
prenatal/labor record and observable physiologic indicators.
MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.
3
Copyright 2016 Pearson Education, Inc.
4) During newborn resuscitation, how does the nurse evaluate the effectiveness
of bag-and-mask ventilations?
1. The rise and fall of the chest
2. Sudden wakefulness
3. Urinary output
4. Adequate thermoregulation
Answer: 1
Explanation: 1. With proper resuscitation, chest movement is observed for
proper ventilation. Pressure should be adequate to move the chest wall.
Page Ref: 814
Cognitive Level: Remembering
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches. | NLN Competencies:
Relationship-Centered Care: Factors that contribute to or threaten health. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1 Describe how to identify infants in need of
resuscitation and the appropriate method of resuscitation based on the
prenatal/labor record and observable physiologic indicators.
1) The nurse prepares to admit to the nursery a newborn whose mother had
meconium-stained amniotic fluid. The nurse knows this newborn might require
which of the following?
1. Initial resuscitation
2. Vigorous stimulation at birth
3. Phototherapy immediately
4. An initial feeding of iron-enriched formula
Answer: 1
Explanation: 1. The presence of meconium in the amniotic fluid indicates that
the fetus may be suffering from asphyxia. Meconium-stained newborns or
newborns who have aspirated particulate meconium often have respiratory
depression at birth and require resuscitation to establish adequate respiratory
effort.
Page Ref: 826
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing
interventions as appropriate for managing the acute and chronic care of patients
and promoting health across the lifespan. | NLN Competencies: Quality and
Safety: Communicate potential risk factors and actual errors. |
,Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2 Differentiate, based on clinical manifestations, among the
various types of respiratory distress (respiratory distress syndrome, transient
tachypnea of the newborn, meconium aspiration syndrome, and persistent
pulmonary hypertension) in the newborn and each types related nursing care.
MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their
associated nursing care.
1
Copyright 2016 Pearson Education, Inc.
2) A laboring mother has recurrent late decelerations. At birth, the infant has
a heart rate of 100, is not breathing, and is limp and bluish in color. What
nursing action is best?
1. Begin chest compressions.
2. Begin direct tracheal suctioning.
3. Begin bag-and-mask ventilation.
4. Obtain a blood pressure reading.
Answer: 3
Explanation: 3. Most newborns can be effectively resuscitated by bag-and-
mask ventilation.
Page Ref: 814
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing
interventions as appropriate for managing the acute and chronic care of patients
and promoting health across the lifespan. | NLN Competencies: Quality and
Safety: Communicate potential risk factors and actual errors. |
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1 Describe how to identify infants in need of
resuscitation and the appropriate method of resuscitation based on the
,prenatal/labor record and observable physiologic indicators.
MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their
associated nursing care.
2
Copyright 2016 Pearson Education, Inc.
3) Which fetal/neonatal risk factors would lead the nurse to anticipate a
potential need to resuscitate a newborn?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Nonreassuring fetal heart rate pattern/sustained bradycardia
2. Fetal scalp/capillary blood sample pH greater than 7.25
3. History of meconium in amniotic fluid
4. Prematurity
5. Significant intrapartum bleeding
Answer: 1, 3, 4, 5
Explanation: 1. Nonreassuring fetal heart rate pattern/sustained bradycardia
would be considered a potential need to resuscitate a newborn.
3. History of meconium in amniotic fluid would be considered a potential
need to resuscitate a newborn.
4. Prematurity would be considered a potential need to resuscitate a newborn.
5. Significant intrapartum bleeding would be considered a potential need to
resuscitate a newborn.
Page Ref: 812
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
, developmentally and culturally appropriate approaches. | NLN Competencies:
Relationship-Centered Care: Factors that contribute to or threaten health. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1 Describe how to identify infants in need of
resuscitation and the appropriate method of resuscitation based on the
prenatal/labor record and observable physiologic indicators.
MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.
3
Copyright 2016 Pearson Education, Inc.
4) During newborn resuscitation, how does the nurse evaluate the effectiveness
of bag-and-mask ventilations?
1. The rise and fall of the chest
2. Sudden wakefulness
3. Urinary output
4. Adequate thermoregulation
Answer: 1
Explanation: 1. With proper resuscitation, chest movement is observed for
proper ventilation. Pressure should be adequate to move the chest wall.
Page Ref: 814
Cognitive Level: Remembering
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused
physical, behavioral, psychological, spiritual, socioeconomic, and
environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches. | NLN Competencies:
Relationship-Centered Care: Factors that contribute to or threaten health. |
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1 Describe how to identify infants in need of
resuscitation and the appropriate method of resuscitation based on the
prenatal/labor record and observable physiologic indicators.
