Which preterm infant should receive gavage feedings instead of bottle feedings?

Has a sustained respiratory rate of 70 breaths per minute

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?

Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.

A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is

lack of subcutaneous fat.

In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level?

Retinopathy of prematurity (ROP)

In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n)

blood glucose level of 25 mg/dL.

Which statement regarding newborns classified as small for gestational age (SGA) is accurate?

They are below the tenth percentile on gestational growth charts.

Which nursing action is especially important for an SGA newborn?

Prevent hypoglycemia with early and frequent feedings

What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction?

The head seems large compared with the rest of the body.

Which data should alert the nurse caring for an SGA infant that additional calories may be needed?

Three successive temperature measurements were 36.1°C, 35.5°C, and 36.1°C (97, 96, and 97°F).

Which statement regarding large-for-gestational age (LGA) infants is most accurate?

They are prone to hypoglycemia, polycythemia, and birth injuries.

Following the vaginal birth of a macrosomic infant, the nurse should evaluate the infant for

clavicle fractures.

An infant delivered prematurely at 28 weeks’ gestation weighs 1200 g. Based on this information the infant is classified as

VLBW

The nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant’s color and heart rate remain unchanged. The nurse suspects that the infant

is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit.

Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?

Fluid volume deficit related to phototherapy treatment

An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of

PIVH.

Following a traumatic birth of a 10-lb infant, the nurse should evaluate

flexion of both upper extremities.

A newborn assessment finding that would support the nursing diagnosis of postmaturity would be

loose skin.

Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.)

Sepsis

Hyperbilirubinemia

Problems with thermoregulation

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to

provide fluids and protein.

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority?

Test for the blood glucose level.

Which newborn should the nurse recognize as being at the greatest risk for developing respiratory distress syndrome?

A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes.

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of

inadequate absorption of fetal lung fluid.

The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of

persistent pulmonary hypertension.

The nurse present at the birth is reporting to the nurse who will be caring for the neonate after the delivery. Prior to birth there was meconium present in the amniotic fluid. The infant presented with depressed respirations and weak muscle tone. Which information should be included in the report for this infant?

The infant required warmed humidified oxygen

Which intervention will increase the effectiveness in reducing the indirect bilirubin in an affected newborn?

Turn the infant every 2 hours.

Newborns whose mothers are substance abusers frequently exhibit which of the following behaviors

Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find

signs of congestive heart failure.

In an infant with cyanotic cardiac anomaly, the nurse should expect to see

little to no improvement in color with oxygen administration

The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice

appears during the first 24 hours of life.

Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal in intensive care unit(NICU) for closer observation, with a diagnosis of transient tachypnea of the neonate (TTN).The parents are notified and become anxious because they have no understanding of what this means for their infant. The best action that the nurse can take at this time is to

explain to them that this often occurs following a birth and it will most likely resolve in the next 24 to 48 hours.

While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth?

Risk for aspiration related to retained secretions

Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant?

Infant bilirubin level

Which of the following lab values indicates that an infant may have polycythemia?

Hct 70%

The nurse notes that the infant has been feeding poorly over the last 24 hours. The nurse should immediately assess for other signs of

neonatal infection.

The priority assessment for the Rh-negative infant whose mother’s indirect Coombs test was positive at 36 weeks is

skin color.

The nurse should be alert to a blood group incompatibility if

mother is B-positive and infant is O-negative.

Infection can be transmitted to the neonate from mother during the pregnancy or birth or from the mother, family members, visitors, or agency staff after birth which viral infections are most likely to be transmitted during the birth process? (Select all that apply.)

Hepatitis B

Herpes

Cytomegalovirus

The drug-exposed infant often presents with irritability, frantic crying, and is difficult to console. Which nursing measures can be used to prevent this behavior in this high-risk infant?(SATA)

Swaddle the infant.

Rock slowly and gently.

Coo softly and gently.

Which contraceptive method provides protection against sexually transmitted diseases?

Male or female condoms

A nurse is leading a discussion regarding options for birth control. Which of the following methods is considered the most reliable?

Intrauterine device

Which patient is a safe candidate for the use of oral contraceptives?

43-year-old who does not smoke cigarettes.

The role of the nurse in family planning is to

educate couples on the various methods of contraception.

Informed consent concerning contraceptive use is important since some of the methods

have potentially dangerous side effects.

Which contraceptive method should be contraindicated in a patient with a history of toxic shock syndrome?

Cervical cap

When instructing a patient in the use of spermicidal foam or gel, it is important to include the information that

douching should be avoided for at least 6 hours.

Which symptom in a patient using oral contraceptives should be reported to the physician immediately

Leg pain and edema

When using the basal body temperature method of family planning, the woman should understand that

her temperature will increase about 0.2 to 0.4°C (0.4 to 0.8°F) after ovulation.

The major difference between the diaphragm and the cervical cap is that the diaphragm

applies pressure on the urethra.

The patient who has had an intrauterine device (IUD) inserted should be instructed to

check the placement of the string once a week for 4 weeks.

A male patient asks, “Why do I have to use another contraceptive? I had a vasectomy last week.” The best response is

Complete sterilization doesn’t occur until all sperm have left the system

A woman who has a successful career and a busy lifestyle will most likely look for which type of contraceptive?

Is the easiest and most convenient to use

The method of contraception that is considered the safest for women is a(n)

male condom.

A patient is 27 years old and delivered her first baby yesterday. She and her husband do not want to have another baby for at least 3 to 4 years. The most appropriate method of birth control to meet their needs is

combination of condoms and foam.

The most appropriate statement for introducing the topic of family planning in the postpartum setting is

What are your plans for future pregnancies?”

In reviewing information related to the occurrence of pregnancies using a focus group discussion with women, concern was expressed that many of them had problems using their respective type of contraception. As a result of noncompliance issues several women became pregnant. Based on this information, the nurse would incorporate which of the following in a teaching plan for group members?

Plan for assessing the patients’ knowledge related to the contraception methods and provide information to increase the knowledge base so that the effectiveness rate would improve.

You are teaching a group of adolescents regarding myths and facts related to contraception. Which statement indicates that additional teaching is needed for this group?

The withdrawal technique provides a higher likelihood that a teen will not get pregnant.

A patient presents to the Women’s Health Clinic for continuation of her contraceptive method. She has been using Depo Provera(medroxyprogestrone acetate) for 24 months. In preparation for instituting a plan of care, the nurse would consider which option as priority

Obtain information for an alternate contraception method

Which of the following statements is correct regarding the use of contraception and the occurrence of sexually transmitted diseases (STDs)

Barrier methods, if used correctly, are more likely to protect individuals from STDs as compared with other contraceptive methods.

Which of the following is a potential disadvantage for the patient who wishes to use an intrauterine device (IUD) as a method of birth control

Ectopic pregnancy

A patient is using Depo-Provera as her method of Which clinical finding warrants immediate intervention by the nurse?

Mid-cycle bleeding

A patient has had a prior history of endometriosis and comes to the clinic asking about which method of birth control might be helpful to alleviate her symptoms. Which birth control method would provide the greatest benefit to this patient?

Oral contraceptives

You are evaluating a patient in the clinic setting who has been taking oral contraceptives for several years, without side effects. Vital signs are stable and the patient denies any pain or tenderness. On examination, you note a small erythematous area of approximately 2 cm on her right lower leg. She denies any traumatic injury and says this is a recent onset of a few days. Based on this information you would

refer the patient to the health care provider for additional diagnostic work up.