MN Exam3 High Risk Neonatal NCLEX 30 Questions with Verified Answers,100% CORRECT, Study notes of Nursing

Download MN Exam3 High Risk Neonatal NCLEX 30 Questions with Verified Answers,100% CORRECT and more Study notes Nursing in PDF only on Docsity! MN Exam3 High Risk Neonatal NCLEX 30 Questions with Verified Answers A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as: a. Low birth weight b. Very low birth weight c. Extremely low birth weight d. Very premature - CORRECT ANSWER a. Low birth weight Rationale: Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight. A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC) - CORRECT ANSWER d. Necrotizing Enterocolitis (NEC) Rationale: Assessment findings related to NEC include abdominal distention, bloody stools, abdominal distention, vomiting, and increased gastric residual. These signs and symptoms are related to the premature neonate's inability to fully digest stomach contents and limitation in absorptive function. A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions? a. Phototherapy b. Feeding neonate every 2 to 3 hours c. Switch from breastfeeding to bottle feeding d. Assess red blood cell count - CORRECT ANSWER b. Feeding neonate every 2 to 3 hours Rationale: Adequate hydration promotes excretion of bilirubin in the urine. Phototherapy is considered when the levels are 12 mg/dL or higher when the neonate is 25 to 48 hours old. Neonates re-absorb increased amounts of unconjugated bilirubin in the intestines due to lack of intestinal bacteria and decreased gastrointestinal motility. Colostrum acts as a laxative and assists in the passage of meconium. Assessing RBC is not a treatment for hyperbilirubinemia. A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?" b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?" c. "Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health?" d. "I see that this is very upsetting for you. I will come back later and answer your questions." - CORRECT ANSWER c. "Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health?" Rationale: Correct. This response answers her questions and allows her to ask additional questions about her baby's health. A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following? Rationale: Although there is nothing in the scenario that states that the amniotic fluid is green tinged, post-term babies are high risk for meconium aspiration syndrome. A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom? a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash - CORRECT ANSWER c. Repeated bouts of diarrhea Rationale: Babies who are experiencing withdrawal often experience bouts of diarrhea. A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby? a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele - CORRECT ANSWER a. Grunting Rationale: This infant is high risk for respiratory distress. The nurse should observe this baby carefully for grunting. The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurse interprets the result as which of the following? a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia. - CORRECT ANSWER a. The baby's lung fields are mature. Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level? a. Low glucose b. Poor feeding c. Hyperactivity d. Hyperthermia - CORRECT ANSWER b. Poor feeding Rationale: The baby is likely to feed poorly. An elevated bilirubin level adversely affects the central nervous system. Babies are often sleepy and feed poorly when the bilirubin level is elevated. The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700 gram infant at 36 weeks' gestation. The most appropriate term for this is: a. Preterm birth b. Term birth c. Small for gestational age infant d. Large for gestational age infant - CORRECT ANSWER a. Preterm birth Rationale: A preterm infant is an infant with gestational age of fewer than 36 completed weeks. The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: a. Lecithin b. Calcium c. Surfactant d. Magnesium - CORRECT ANSWER c. Surfactant Rationale: Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The pathology of RDS is that there is diffuse atelectasis with congestion and edema in the lung spaces. On deflation, the alveoli collapse, and there is decreased lung compliance. The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milk every 3 hours. The nurse's best response to the patient's mother would be: a. "Pumping is hard work and you are doing very well. It is good to get about 1 ounce of milk every 3 hours." b. "Natural breastfeeding will be a challenging goal for your baby. Beginning today, you will need to begin to pump your breasts more often." c. "Your baby will not be ready to go home for at least another week. You can begin to pump more often in the next few days in preparation for taking your child home." d. "You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more of - CORRECT ANSWER d. "You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more often to prepare to take your baby home." Rationale: The mother should be praised for her efforts to breastfeed and encouraged to continue to pump her milk. A determined schedule for pumping the milk will help the mother keep her milk flow steady and provide enough nutrients for the infant after discharge. A nurse is caring for a 2-day-old neonate who was born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.) a. Exogenous surfactant b. Corticosteroids Which of the following are common assessment findings of postmature neonates? (Select all that apply.) a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance - CORRECT ANSWER a. Dry and peeling skin c. Hypoglycemia d. Thin, wasted appearance Rationale: Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. Vernix prevents water loss from the skin to the amniotic fluid; as the amount of vernix decreases, an increasing amount of water is lost from the skin. This contributes to the dry and peeling skin seen in postmature neonates. c. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth. d. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth. A nurse is caring for a 40 weeks' gestation neonate. The neonate is 12 hours post- birth and has been admitted to the NICU for meconium aspiration. The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins - CORRECT ANSWER a. Obstructed airway b. Hyperinflation of the alveoli d. Decreased surfactant proteins Rationale: The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. The presence of meconium in the lungs can also cause a chemical pneumonitis and inhibit surfactant production. A nurse is completing the initial assessment on a neonate of a mother with type I diabetes. Important assessment areas for this neonate include which of the following? (Select all that apply.) a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system - CORRECT ANSWER a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system Rationale: a. Neonates of mothers with type I diabetes are at higher risk for cardiac anomalies. b. Neonates of mothers with type I diabetes are at higher risk for RDS due to a delay in surfactant production related to high maternal glucose levels. c. Neonates of mothers with type I diabetes are usually large and are at risk for a fractured clavicle. d. Neonates of mothers with type I diabetes are at higher risk for neurological damage and seizures due to neonatal hyperinsulinism. A baby was born 4 days ago at 34 weeks' gestation. She is receiving phototherapy as ordered by the physician for physiological jaundice. She has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. The nurse's priority nursing action(s) is (are) to (select all that apply): a. Verify laboratory results to check for hypomagnesia. b. Verify laboratory results to check for hypoglycemia. c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration. - CORRECT ANSWER c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration. Rationale: There are two priority nursing interventions for hyperbilirubinemia. Hydration status is important if the newborn shows signs of dehydration such as dry skin and mucus membranes, poor intake, concentrated urine or limited urine output, and irritability. The newborn should also be kept warm while receiving phototherapy. When an infant is under phototherapy, the temperature needs to be monitored closely because the lights give off extra heat, but if the newborn is in an open crib and undressed, hypothermia may occur. Hypomagnesia and hypoglycemia are not related to phototherapy. The perinatal nurse caring for Emily, a 24-year-old mother of an infant born at 26 weeks' gestation, is providing discharge teaching. Emily is going to travel to the specialty center approximately 200 miles away where her daughter is receiving care. The nurse tells Emily that it is normal for Emily to feel (select all that apply): a. In control b. Anxious c. Guilty d. Overwhelmed - CORRECT ANSWER b. Anxious c. Guilty d. Overwhelmed A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication? (Select all that apply.) a. Cholecystitis b. Hypertension c. Cigarette smoker d. Candidiasis