CH 17

Chapter 17 High-Risk Neonatal Nursing Care
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse in NICU is assessing a neonate delivered at 32 weeks gestation. Which
pathophysiological manifestation is the nurse’s greatest concern?
1. Absent or weak reflexes
2. Presence of a heart murmur
3. Apnea 20 seconds or longer
4. Low hemoglobin lab level
____ 2. The labor and delivery nurse is present for the delivery of a premature neonate. Which action by
the nurse is most important?
1. Stabilize and transfer neonate to NICU.
2. Review pregnancy history for risk factors.
3. Maintain fluid and electrolyte balance.
4. Provide a neutral temperature environment.
____ 3. The nurse is providing care for a premature neonate in the NICU nursery. The neonate is
diagnosed with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA). Which
specific intervention does the nurse expect for this neonate?
1. Monitor of hemoglobin and hematocrit levels.
2. Obtain blood glucose levels.
3. Maintain fluid restrictions.
4. Administer enteral feedings.
____ 4. A mother of a premature neonate in NICU asks the nurse when her baby will begin getting oral
feedings. The nurse is aware that multiple conditions are desired. Which condition is most
essential?
1. The neonate demonstrates proper feeding actions.
2. The neonate exhibits cardiorespiratory regulation.
3. The neonate is able to demonstrate hunger cues.
4. The neonate is able to maintain a quiet alert state.
____ 5. The NICU nurse encourages the mother of a premature neonate to bring breast milk to the unit for
enteral feedings to her baby. For which reason does the nurse make this suggestion?
1. The baby will be more likely to breastfeed later.
2. The mother will feel more involved with the baby.
3. The neonate will gain weight faster on breast milk.
4. Breast milk helps prevent necrotizing enterocolitis.
____ 6. The nurse is providing care for a premature neonate born at 28 weeks gestation who is
experiencing respiratory distress syndrome (RDS). Which assessment finding indicates to the
nurse that the neonate’s respiratory status is deteriorating?
1. Pao2 is 48 and Paco2 is 55 mm Hg on 90% oxygen.
2. Respiratory rate is 58 breaths per minute.
3. Breath sounds on auscultation are decreased.
4. Heart rate is 162 beats per minute.
____ 7. The nurses in a NICU are concerned about the appropriate levels of oxygen therapy during the care
of premature neonates. The nurses referenced an article by Newman (2014) titled, “Oxygen
Saturation Limits and Evidence supporting the Targets.” On which evidence-based conclusion will
the nurses develop guidelines?
1. Oxygen saturation limits of 85% to 89% are effective.
2. Oxygen saturation rates of 91% to 95% are effective.
3. Infants are within saturation limits about 75% of the time.
4. Oxygen saturation limits need to be between 87% to 94%.
____ 8. A patient who is at 41 weeks gestation is concerned when the primary care provider decides to
induce labor. Which reason does the nurse explain as the most important need for this procedure?
1. Increasing size of the neonate
2. Ability to deliver vaginally
3. Risk for placental dysfunction
4. Likelihood of meconium aspiration
____ 9. The nurse notices that a neonate being treated for hyperbilirubinemia with phototherapy has had a
daily increase of total bilirubin serum levels greater than 5 mg/dL for the past 2 days. The neonatal
care provider prescribes an exchange transfusion. Which knowledge does the nurse apply to the
procedure?
1. The bilirubin indicates a severe hemolytic disease.
2. Approximately 85% of the neonate’s RBCs are replaced.
3. Donor RBCs are obtained from the neonate’s mother.
4. The procedure is exclusive to pathological jaundice.
____ 10. The nurse is preparing for the discharge of a premature neonate to home with the parents. The
nurse explains the neonate must be able to pass the infant car seat challenge before discharge. For
which reason would the neonate be considered unsafe in a car seat?
1. Inability to remain at a 45-degree angle for a period of 1 hour
2. Reluctance of parents to use the car seat because of the small size of the baby
3. Inability to maintain adequate oxygenation, heart rate, and respiratory rate during
trial
4. Inability to continue prescribed oxygen therapy for the neonate while in a car seat
____ 11. The nurse is providing support to a mother whose newborn is diagnosed with a life-threatening
defect. The mother states, “I just want to go home and never come back.” Which reaction by the
mother does the nurse recognize?
1. Guilty feelings by the mother
2. Delay of attachment process
3. Maternal emotional distancing
4. Disruption of family life
____ 12. The nurse is providing support for the parents of a neonate born with anencephaly. The parents
repeatedly state, “I don’t believe this is happening to us. We were so careful during pregnancy.”
The nurse associates the parents’ comments with which stage of grief?
1. Disbelief
2. Depression
3. Denial of reality
4. Anger with each other
____ 13. The nurse is present in the delivery room when a mother is told her neonate was stillborn. The
mother begins to wail loudly and pull at her hair. Which action does the nurse take?
1. Allow the mother to express grief in her own way.
2. Attempt to calm the mother and prevent self-harm.
3. Ask for a sedative to calm the mother’s reaction.
4. Ask a family member to comfort the mother.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 14. The premature neonate is more susceptible to skin breakdown than a term neonate. Which skin
care interventions will the nurse implement for the premature neonate? Select all that apply.
1. Use a neutral pH cleanser and sterile water for bathing.
2. Gently apply emollients to avoid unnecessary friction.
3. Perform daily skin assessment to identify problems early.
4. Use water, air, or gel mattresses.
5. Provide a full bath every other day.
____ 15. The postnatal nurse is providing care for a neonate being treated with phototherapy for
hyperbilirubinemia. For which side effects of phototherapy will the nurse contact the neonatal care
provider? Select all that apply.
1. Hyperthermia
2. Lethargy
3. Hypocalcemia
4. Thrombocytopenia
5. Bronze baby syndrome
____ 16. The nurse is preparing for the discharge of a neonate diagnosed with a congenital breathing
disorder. Which health team members does the nurse include in discharge planning? Select all that
apply.
1. Respiratory therapist
2. Community agency manager
3. Social worker
4. Home health agency nurse
5. Case manager
____ 17. The nurse is providing support to parents of a premature neonate in NICU. Which actions by the
nurse will best provide psychosocial support to the parents? Select all that apply.
1. Assess the parents’ ability to care for their neonate.
2. Ask the parents how they are coping with the experience.
3. Provide equipment for breast pumping and storage of milk.
4. Encourage parents to take photos to share with family and friends.
5. Praise parents for their involvement in the care of their neonate.
____ 18. The nurse is providing care for a neonate born to a mother with preexisting diabetes mellitus.
Which neonatal assessment findings do the nurse expect? Select all that apply.
1. Macrosomia
2. Hyperglycemia
3. Hypocalcemia
4. Jaundice
5. Dyspnea
Completion
Complete each statement.
19. ____________________ is a chronic lung problem that affects neonates who have been treated
with mechanical ventilation and oxygen for problems such as RDS.
Chapter 17 High-Risk Neonatal Nursing Care
Answer Section
MULTIPLE CHOICE
1. ANS: 3
Chapter: Chapter 17 High-Risk Neonatal Nursing Care
Chapter Learning Objective: 1. Describe the physiology and pathophysiology associated with
selected complications of the neonatal period.
Page: 507
Heading: Preterm Neonates > Assessment Findings
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
Concept: Ante/Intra/Post-partum
Difficulty: Moderate
Feedback
1 This is incorrect. Absent or weak reflexes are expected in a premature neonate
because of neurologic immaturity.
2 This is incorrect. In a premature neonate, the presence of a heart murmur is
related to a patent ductus arteriosus. This finding is indicative of circulation
status; however, it is still not the nurse’s greatest concern.
3 This is correct. Apnea for 20 seconds or longer is the nurse’s greatest concern.
Even though this is expected in premature neonates, the nurse will still focus on
ABCs.
4 This is incorrect. Anemia is not unexpected in a premature neonate. While this
finding is a concern because of a reduction in the blood’s ability to carry
sufficient oxygen, the greatest concern is still breathing issues.
PTS: 1 CON: Ante/Intra/Post-partum

2. ANS: 4
Chapter Learning Objective: 2. Identify critical elements of assessment and nursing care of the
high-risk neonate.
Page: 508
Heading: Preterm Neonates > Nursing Actions
Client Need: Physiological Integrity: Reduction of Risk Potential
Difficulty: Difficult
Feedback
1 This is incorrect. The premature neonate will need to be stabilized and moved to
NICU for specialized care; however, this is not the nurse’s most important
action at the immediate time of birth.
2 This is incorrect. Review of the mother’s pregnancy history in order to identify
risk factors related to prematurity is not an immediate concern.
3 This is incorrect. The nurse in NICU is likely to be involved in maintaining fluid
and electrolyte balance.
4 This is correct. When attending a premature birth, the most important nursing
action is to provide a neutral temperature environment (NTE). The premature
neonate is at risk for increased loss of heat because of diminished amounts of
subcutaneous fat. The nurse needs to take measures to prevent cold stress, which
can be fatal.

3. ANS: 3
high-risk neonate.
Page: 509
Feedback
1 This is incorrect. Monitoring hemoglobin and hematocrit levels is an expected
intervention for premature neonates.
2 This is incorrect. Obtaining blood glucose levels is an expected intervention for
premature neonates.
3 This is correct. Maintaining fluid restrictions is specific for this neonate due to
bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA). Fluid
restrictions are appropriate for premature neonates with BPD, PDA, or other
complications that can lead to pulmonary edema.
4 This is incorrect. Administering enteral feedings is an expected intervention for
premature neonates.

4. ANS: 2
high-risk neonate.
Page: 510
Feedback
1 This is incorrect. A premature neonate needs to be able to suck, swallow, and
breathe before oral feedings can be initiated. However, this is not the most
essential condition.
2 This is correct. The nurse will observe the neonate for respiratory status, apnea,
bradycardia, oxygenation, and feeding tolerance. The neonate needs to exhibit
cardiorespiratory regulation before oral feedings are started. This is the most
essential condition for oral feedings.
3 This is incorrect. When a neonate demonstrates hunger cues (bringing hand to
the mouth, sucking on fingers), oral feedings can be considered. However, it is
not the most essential condition.
4 This is incorrect. The ability of a neonate to maintain a quiet alert state is
important for successful oral feeding; however, it is not the most essential
condition.

5. ANS: 4
high-risk neonate.
Page: 510
Heading: Premature Neonates > Nursing Actions
Cognitive Level: Application [Applying]
Feedback
1 This is incorrect. The premature neonate is more likely to breastfeed later if the
mother and neonate are able to breastfeed before discharge from NICU.
2 This is incorrect. Bringing breast milk to her neonate is likely to make the
mother feel involved. However, the mother can be involved regardless of the
source of nutrition.
3 This is incorrect. Human milk requires fortification because it does not provide
the calories, protein, fat, carbohydrate, potassium, calcium, sodium, and
phosphorus that the premature infant needs
4 This is correct. It is a known fact that babies fed on breast milk are less likely to
develop necrotizing enterocolitis.

6. ANS: 1
Page: 512
Heading: Respiratory Distress Syndrome
Feedback
1 This is correct. A sign that the neonate’s respiratory status is deteriorating is if
increased oxygen levels fail to maintain a Pao2 and Paco2 within normal limits.
The normal range of Pao2 is 60 to 70 mm Hg and the normal range of Paco2 is
35 to 45 mm Hg. The neonate is unable to maintain a normal range on 90%
oxygen, which is a sign of deterioration.
2 This is incorrect. A respiration rate of 58 breaths per minute is considered
normal. With RDS, the respiration rate is expected to be greater than 60 breaths
per minute.
3 This is incorrect. An expected finding for a neonate with RDS is decreased
breath sounds with auscultation. Rales are present as RDS progresses and the
neonate deteriorates.
4 This is incorrect. With RDS, the heart rate is expected to be greater than 160
beats per minute. This is an expected finding and does not necessarily indicate
deterioration.

7. ANS: 4
Page: 518
Heading: Retinopathy of Prematurity
Feedback
1 This is incorrect. Lower oxygen saturation limits of 85% to 89% were
associated with increased risk for neonatal death.
2 This is incorrect. Higher oxygen saturation rates of 91% to 95% were associated
with increased ROP rates.
3 This is incorrect. Infants are within saturation limits about 31% of the time and
require multiple oxygen adjustments hourly.
4 This is correct. Rapid and consistent assessment with appropriate interventions
are required to maintain oxygen saturation limits of 87% to 94% to decrease risk
of ROP and neonatal death.

8. ANS: 3
Chapter Learning Objective: Describe the physiology and pathophysiology associated with
Page: 519
Heading: Postmature Neonates > Complications
Feedback
1 This is incorrect. The postmature neonate may or may not exhibit an increase in
size. The postmature neonate can have a thin, wasted appearance if placental
insufficiency has caused the fetus to use its subcutaneous fat stores and
glycemic stores. Increasing size is not the most important need for labor
induction.
2 This is incorrect. Macrosomia may interfere with the mother’s ability to
vaginally deliver a postmature fetus, and the fetus is at risk for birth trauma.
However, this is not the most important need for labor induction.
3 This is correct. With the postmature fetus, the greatest reason to induce labor is
to minimize complications related to placental dysfunction. With postmaturity,
placental function decreases, resulting in altered oxygenation and nutrient
transport, which increases the risk for hypoxia and hypoglycemia at the onset of
labor. This is the most important reason for labor induction.
4 This is incorrect. The risk for meconium aspiration may or may not occur as a
result of postmaturity. This is not the most important reason for labor induction.

9. ANS: 2
high-risk neonate.
Page: 525
Heading: Hyperbilirubinemia > Pathological Jaundice
Difficult: Difficult
Feedback
1 This is incorrect. Exchange transfusion is used in cases where phototherapy is
not effective for hyperbilirubinemia or severe hemolytic disease is present.
Hyperbilirubinemia is identified in the scenario; however, there is no reference
to severe hemolytic disease.
2 This is correct. The nurse is aware that approximately 85% of the neonate’s
RBCs are replaced with donor cells.
3 This is incorrect. Donor cells are not specifically obtained from the neonate’s
mother.
4 This is incorrect. This procedure reduces bilirubin, removes RBCs coated with a
maternal antibody, corrects anemia, and removes other toxins associated with
hemolysis. The procedure is not exclusive to the treatment of pathological
jaundice.

10. ANS: 3
Chapter Learning Objective: 3. Develop a discharge plan for high-risk neonates.
Page: 543
Heading: Discharge Planning
Feedback
1 This is incorrect. The infant car seat challenge actually requires the neonate to
be secured snugly in an appropriate-sized car seat at a 45-degree angle for a
specified amount of time, which may be related to the distance between the
neonate’s home, or the distance to medical facilities.
2 This is incorrect. The parents need to be advised that car seats, or inserts, are
available to accommodate the small size of a premature neonate.
3 This is correct. In order to pass the infant care seat challenge, the premature
neonate must be able to maintain adequate oxygenation, heart rate, and
respiratory rate during trial.
4 This is incorrect. If the premature neonate is prescribed oxygen therapy, the
therapy can and must be maintained while the neonate is in a car seat.

11. ANS: 3
Chapter Learning Objective: 4. Describe the loss and grief process experienced by parents whose
infant has died.
Page: 545
Heading: Psychosocial Needs of Parents with High-Risk Neonates
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Feedback
1 This is incorrect. Guilty feelings by the mother, who may feel she did something
wrong to cause her newborn to be ill, may be an expected reaction. However,
the mother is not voicing feelings of guilt.
2 This is incorrect. Delay of attachment process is due to the separation of parent
and newborn, which can place the newborn at risk for abuse and neglect.
However, there is no information supporting a delay of attachment in this
scenario.
3 This is correct. Emotional distancing of parents from their newborn is a
protective mechanism related to fear of their child’s death. The mother’s
comment reflects emotional distancing.
4 This is incorrect. Disruption of family life occurs because of parents needing to
return to work, caring for other children, and at the same time wanting to spend
time in the hospital with their newborn. There is no information supporting the
disruption of family life in the scenario or in the mother’s comment.

12. ANS: 1
infant has died.
Page: 545
Heading: Loss and Grief
Feedback
1 This is correct. The parents’ comments indicate that they are experiencing the
stage of grief associated with avoidance, disbelief, shock, or guilt.
2 This is incorrect. Pain, physical discomfort, depression, difficulty concentrating,
and anger at self or partner are stages of grief. The parents’ comments do not
reflect depression.
3 This is incorrect. Denial of reality is not expressed in the parents’ comments.
Denial is not specifically relative to loss and grief associated with a child.
4 This is incorrect. The parents’ comments do not reflect anger with each other;
the emotion expressed is more closely related to disbelief.

13. ANS: 1
infant has died.
Page: 545
Heading: Loss and Grief
Feedback
1 This is correct. Culture, religion, and personal experience and beliefs will
impact how individuals and families respond to loss. The nurse needs to support
the mother and allow her to grieve in her own way.
2 This is incorrect. Attempts to calm the mother are likely to be ineffective. The
nurse will protect the mother from self-harm, but hair pulling does not place the
mother in physical danger.
3 This is incorrect. Asking for a sedative to calm the mother will just delay the
mother’s expression of grief. Nurses must keep in mind that each person
experiences and expresses grief in his or her own way.
4 This is incorrect. Asking a family member to comfort the mother may not be
effective due to the grief the family members will also experience. The mother
needs support now, and the nurse will help fill this need immediately.
MULTIPLE RESPONSE
14. ANS: 1, 2, 4
high-risk neonate.
Page: 511
Heading: Premature Neonates > Nursing Actions
Feedback
1 This is correct. Use a neutral pH cleanser and sterile water for bathing to help prevent
skin breakdown on a premature neonate.
2 This is correct. Emollients should be applied gently to avoid unnecessary friction,
which can cause skin breakdown.
3 This is incorrect. Skin assessment on a premature neonate needs to be performed
whenever the neonate is repositioned or the diaper is changed. Once daily is not
frequently enough for early identification of potential problems.
4 This is correct. Water, gel, or air mattresses are used to help prevent skin breakdown in
the premature neonate.
5 This is incorrect. Premature neonates do not receive complete baths; the soiled areas
are cleaned as needed.

15. ANS: 1, 3, 4
high-risk neonate.
Page: 527
Heading: Hyperbilirubinemia > Nursing Actions for Hyperbilirubinemia
Feedback
1 This is correct. The nurse will recognize hyperthermia as an elevation of temperature in
the neonate. The nurse will report this assessment finding to the neonatal care provider.
2 This is incorrect. Lethargy is a common manifestation related to hyperbilirubinemia.
The nurse will report bilirubin levels to the neonatal care provider, but not necessarily
the presence of lethargy.
3 This is correct. Hypocalcemia in a neonate is a serum calcium level below 7.5 mg/dL.
Neonatal hypocalcemia symptoms are often similar to those of hypoglycemia and
include jitteriness, tetany, and seizures. The nurse will report this assessment finding to
the neonatal care provider.
4 This is correct. Thrombocytopenia is indicative of a deficiency of platelets in the blood,
which can result in bruising or bleeding. The nurse will report this assessment finding to
the neonatal care provider.
5 This is incorrect. Bronze baby syndrome is identified by a dark gray-brown
pigmentation of skin that disappears after phototherapy is discontinued. There is no
reason for the nurse to report this assessment finding to the neonatal care provider.
16. ANS: 1, 3, 4, 5
Chapter Learning Objective: 3. Develop a discharge plan for high-risk neonates.
Page: 543
Heading: Discharge Planning
Client Need: Physiological Integrity/ Reduction of Risk Potential
Feedback
1 This is correct. The nurse will include the respiratory therapist in the discharge planning
for a neonate with a congenital breathing disorder. Respiratory therapy may be a
significant lifetime need for this neonate.
2 This is incorrect. The nurse would not include a community agency manager in the
discharge planning for a neonate with a congenital breathing disorder.
3 This is correct. The social worker will play a key role in helping the family find
agencies that can provide support for the parents and the neonate. Consideration is
focused on meeting financial, psychosocial, and medical needs.
4 This is correct. The family is likely to benefit from a home health agency who can assist
with the physiological needs of the neonate. This may be a long-term or short-term need,
but the nurse would include a home agency nurse in discharge planning.
5 This is correct. The case manager is included in the discharge planning because the
family with a neonate with a congenital breathing disorder is likely to have needs for
special equipment and/or therapies.

17. ANS: 2, 4, 5
infant has died.
Page: 545
Heading: Psychosocial Needs of Parents with High-Risk Neonates > Nursing Actions
Client Need: Physiological Psychosocial Integrity
Feedback
1 This is incorrect. Assessing the parents’ ability to provide care for their neonate is
meeting a physiological need.
2 This is correct. Asking the parents how they are coping with the experience provides the
parents with an opportunity to talk about their feelings and responses. This action by the
nurse is providing psychosocial support.
3 This is incorrect. When the nurse provides equipment for pumping breast milk and
storage, the nurse is meeting a physiological need.
4 This is correct. Encouraging parents to take photos of their neonate to share with family
and friends is providing psychosocial support.
5 This is correct. Praising the parents for their involvement in providing care for their
neonate is meeting the need for psychosocial support.

18. ANS: 1, 3, 4, 5
Chapter Learning Objective: 2, Identify critical elements of assessment and nursing care of the
high-risk neonate.
Page: 531
Heading: Infants of Diabetic Mothers > Assessment Findings
Client Need: Physiological Integrity: Physiological Adaptation
Feedback
1 This is correct. Macrosomia is an expected assessment finding in neonates born to
mothers with preexisting diabetes mellitus.
2 This is incorrect. Hypoglycemia (not hyperglycemia) is an expected assessment finding
in neonates born to mothers with preexisting diabetes mellitus.
3 This is correct. Hypocalcemia is an expected assessment finding in neonates born to
mothers with preexisting diabetes mellitus.
4 This is correct. Hyperbilirubinemia is an expected assessment finding in neonates born
to mothers with preexisting diabetes mellitus, because of polycythemia.
5 This is correct. Dyspnea and respiratory distress syndrome are expected assessment
findings in neonates born to mothers with preexisting diabetes mellitus.
COMPLETION
19. ANS:
Bronchopulmonary dysplasia
high-risk neonate.
Page: 513
Heading: Bronchopulmonary Dysplasia
Feedback: Neonates who are dependent on oxygen beyond 28 days of life and/or have been on
mechanical ventilation are at risk for BPD. This condition leads to decreased lung compliance and
pulmonary function secondary to fibrosis, atelectasis, increased pulmonary resistance, and
overdistention of the lungs. Pulmonary edema results from the increased pulmonary vascular
resistance. The prognosis for infants with BPD is dependent on the severity of the disease and the
infant’s overall health status.

CH 17

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CH 17

Uploaded by

Copyright:

Available Formats

Chapter 17 High-Risk Neonatal Nursing Care

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

PTS: 1 CON: Ante/Intra/Post-partum

You might also like