Advanced Health Assessment of the Neonate Q&A with Rationales, Exams of Nursing

Download Advanced Health Assessment of the Neonate Q&A with Rationales and more Exams Nursing in PDF only on Docsity! NURSING 7302 Advanced Health Assessment of the Neonate Q & A w/ Rationales 2024 1. You are assessing a 2-day-old neonate who was born at 36 weeks gestation. The neonate has a respiratory rate of 60 breaths per minute, nasal flaring, intercostal retractions, and grunting. What is the most likely diagnosis for this neonate? A) Transient tachypnea of the newborn B) Respiratory distress syndrome* C) Meconium aspiration syndrome D) Pneumonia Rationale: Respiratory distress syndrome (RDS) is caused by a deficiency of surfactant in the lungs, which leads to alveolar collapse and impaired gas exchange. RDS is more common in preterm infants, especially those born before 37 weeks gestation. The clinical manifestations of RDS include tachypnea, nasal flaring, intercostal retractions, grunting, and cyanosis. 2. You are examining a 3-day-old neonate who was born at term with a vaginal delivery. The neonate has jaundice, lethargy, poor feeding, and a high-pitched cry. The total serum bilirubin level is 25 mg/dL. What is the most appropriate intervention for this neonate? A) Phototherapy* B) Exchange transfusion C) Intravenous fluids D) Antibiotics Rationale: Phototherapy is the treatment of choice for neonatal hyperbilirubinemia, which is a condition various physical anomalies and developmental delays, such as short stature, ovarian failure, congenital heart defects, and distinctive facial features. Some of the characteristic facial features of TS include micrognathia, low-set ears, webbed neck, shield chest, and widely spaced nipples. B: 1. A nurse is assessing a newborn who was delivered via cesarean section due to suspected macrosomia. Which signs should the nurse prioritize when conducting an advanced health assessment of this neonate? a. Skin color and general appearance b. Heart rate and respiratory effort c. Palpation of fontanels and sutures d. Reflexes and muscle tone Answer: d. Reflexes and muscle tone Rationale: Assessing reflexes and muscle tone in a neonate delivered via cesarean section helps evaluate potential birth injuries, such as brachial plexus or nerve damage, which can affect the newborn's functionality. 2. During an advanced health assessment of a neonate, the nurse notices a high-pitched, shrill cry. Which condition should the nurse suspect in this neonate? a. Hypoglycemia b. Hyperbilirubinemia c. Meconium aspiration syndrome d. Neonatal abstinence syndrome Answer: a. Hypoglycemia Rationale: A high-pitched, shrill cry may indicate central nervous system dysfunction, often observed in neonates with hypoglycemia. This cry can be a result of impaired brain function due to low blood glucose levels. 3. A nurse is conducting an advanced health assessment of a preterm neonate with respiratory distress. Which finding is most concerning? a. Nasal flaring b. Intercostal retractions c. Mild cyanosis while crying d. Occasional grunting sounds Answer: b. Intercostal retractions Rationale: Intercostal retractions indicate severe respiratory distress and increased work of breathing. This finding requires immediate attention and potential intervention to improve the neonate's respiratory function. 4. A nurse is assessing a neonate for congenital heart defects during an advanced health assessment. Which finding is most suggestive of a congenital heart defect? a. Murmurs detected upon auscultation b. Varied color changes in extremities c. Capillary refill less than 2 seconds d. Absence of femoral pulses Answer: a. Murmurs detected upon auscultation Rationale: The presence of murmurs upon auscultation can be indicative of congenital heart defects. Further evaluation, such as an echocardiogram, is necessary for definitive diagnosis and appropriate intervention. 5. During an advanced health assessment, a nurse observes excessive tearing and absence of a blinking reflex in a neonate. Which condition should the nurse suspect? a. Congenital ptosis b. Facial nerve palsy c. Lacrimal duct obstruction d. Corneal abrasion Answer: b. Facial nerve palsy Rationale: Excessive tearing and absence of a blinking reflex in a neonate may suggest facial nerve palsy, which can result from birth trauma. Early identification and appropriate management are essential to prevent further complications. 6. A nurse is conducting an advanced health assessment of a newborn and observes a palpable midline mass in the lower lumbar region. Which condition should the nurse suspect? a. Spinal cord injury b. Sacral dimple c. Neuroblastoma d. Developmental dysplasia of the hip Rationale: A specialized cleft palate nipple is designed to accommodate an infant with a cleft lip and palate, ensuring proper suction and reducing the risk of aspiration during feeding. 11. A nurse is assessing a neonate for signs of neonatal sepsis during an advanced health assessment. Which finding requires immediate action? a. Low-grade fever b. Increase in immature neutrophils c. Mildly elevated C-reactive protein levels d. Poor perfusion and tachycardia Answer: d. Poor perfusion and tachycardia Rationale: Poor perfusion and tachycardia indicate that the neonate is in a critical condition, potentially progressing to septic shock. Immediate intervention, such as blood culture collection and initiating antibiotic therapy, is crucial. 12. During an advanced health assessment, the nurse assesses a neonate with omphalocele. Which intervention should the nurse prioritize? a. Applying a sterile, saline-soaked dressing over the omphalocele b. Encouraging the parents to touch the exposed organs c. Administering a daily dose of folic acid supplement d. Promoting kangaroo care and skin-to-skin contact Answer: a. Applying a sterile, saline-soaked dressing over the omphalocele Rationale: Applying a sterile, saline-soaked dressing over the omphalocele helps protect the exposed organs and prevents infection. This intervention should be initiated promptly after birth. 13. A nurse is assessing a neonate for signs of meconium aspiration syndrome during an advanced health assessment. Which finding is characteristic of this condition? a. Pink, frothy sputum b. Mild nasal congestion c. Transient grunting sounds d. Mild tachypnea upon exertion Answer: a. Pink, frothy sputum Rationale: Pink, frothy sputum is a classic sign of meconium aspiration syndrome, which occurs when the neonate inhales meconium-stained amniotic fluid. It requires immediate attention to prevent potential complications. 14. During an advanced health assessment, a nurse identifies a flat, purplish patch located on a neonate's lower back. Which intervention should the nurse prioritize? a. Initiate immediate phototherapy b. Apply a hydrocortisone cream c. Perform a blood glucose screening d. Evaluate for the presence of a sacral dimple Answer: d. Evaluate for the presence of a sacral dimple Rationale: A flat, purplish patch on a neonate's lower back may indicate the presence of a sacral dimple. Further evaluation is essential to rule out associated anomalies, such as a spinal cord abnormality. 15. A nurse is conducting an advanced health assessment of a neonate and notices enlarged breasts and a scant amount of clear or milky discharge from the nipples. What action should the nurse take? a. Notify the healthcare provider for early hormonal therapy initiation b. Monitor the neonate's temperature for potential signs of infection c. Document the finding and educate the parents about transient neonatal breast development d. Request an ultrasound to evaluate the neonate for potential breast masses Answer: c. Document the finding and educate the parents about transient neonatal breast development Rationale: Enlarged breasts and a scant amount of clear or milky discharge from the nipples are common findings in neonates, resulting from maternal hormones. These findings are transient and require documentation and parental education. levels. Question: A neonate is suspected of having a congenital heart defect. Which assessment finding is indicative of a potential cardiac anomaly? A) Murmur heard at the left sternal border B) Absence of acrocyanosis C) Respiratory rate of 60 breaths per minute D) Presence of a capillary refill time of 3 seconds Answer: A) Murmur heard at the left sternal border Rationale: A murmur heard at the left sternal border raises suspicion of a congenital heart defect and warrants further evaluation. Question: A neonate presents with poor feeding, vomiting, and lethargy. Which condition should the nurse suspect? A) Necrotizing enterocolitis B) Gastroesophageal reflux C) Intussusception D) Hypertrophic pyloric stenosis Answer: D) Hypertrophic pyloric stenosis Rationale: The symptoms described are consistent with hypertrophic pyloric stenosis, which can lead to feeding difficulties and vomiting. Question: A neonate exhibits asymmetric Moro reflex and limited movement of the left arm. What condition should the nurse suspect? A) Brachial plexus injury B) Developmental dysplasia of the hip C) Erb's palsy D) Torticollis Answer: A) Brachial plexus injury Rationale: Asymmetric Moro reflex and limited movement of the arm are indicative of a brachial plexus injury, often resulting from birth trauma. Question: A newborn presents with excessive drooling, difficulty swallowing, and cyanosis. Which condition should the nurse suspect? A) Tracheoesophageal fistula B) Choanal atresia C) Cleft lip D) Esophageal atresia Answer: D) Esophageal atresia Rationale: The symptoms described are consistent with esophageal atresia, a condition where the upper esophagus ends in a blind pouch, leading to difficulty in swallowing and respiratory distress. Question: A newborn demonstrates a positive Barlow test and limited hip abduction. Which condition should the nurse suspect? A) Developmental dysplasia of the hip B) Legg-Calvé-Perthes disease C) Osteogenesis imperfecta D) Congenital hip dislocation Answer: A) Developmental dysplasia of the hip Rationale: A positive Barlow test and limited hip abduction are indicative of developmental dysplasia of the hip, which requires further evaluation and management. Question: A neonate presents with a high-pitched, inspiratory noise and respiratory distress. Which condition should the nurse suspect? A) Laryngomalacia B) Tracheomalacia C) Choanal atresia D) Vocal cord paralysis Answer: A) Laryngomalacia Rationale: The described symptoms are consistent with laryngomalacia, a common cause of stridor in neonates due to floppy laryngeal structures. Question: A neonate is found to have a sacral dimple. What assessment should the nurse perform? A) Assessment for sacral edema B) Neurological assessment C) Assessment for spina bifida occulta D) Musculoskeletal assessment Answer: C) Assessment for spina bifida occulta Rationale: A sacral dimple may indicate the presence of spina bifida occulta, a congenital neural tube defect, necessitating further assessment for proper management. Question: A newborn exhibits poor weight gain, chronic diarrhea, and a distended abdomen. Which condition should the nurse suspect? A) Hirschsprung's disease B) Celiac disease