Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig)

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?
2. Initial resuscitation
3. Vigorous stimulation at birth
4. Phototherapy immediately
5. An initial feeding of iron-enriched formula

Page Ref: 822

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N 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 the nursing care required.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. 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?
2. Begin chest compressions.
3. Begin direct tracheal suctioning.
4. Begin bag-and-mask ventilation.
5. Obtain a blood pressure reading.

Page Ref: 809

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Describe how to identify newborns in need of resuscitation and the appropriate method of resuscitation based on the prenatal/labor record and observable physiologic indicators.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations?
2. The rise and fall of the chest
3. Sudden wakefulness
4. Urinary output
5. Adequate thermoregulation

Page Ref: 808

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Describe how to identify newborns in need of resuscitation and the appropriate method of resuscitation based on the prenatal/labor record and observable physiologic indicators.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. A nurse explains to new parents that their newborn has developed respiratory distress syndrome (R D S). Which of the following signs and symptoms would not be characteristic of R D S?
2. Grunting respirations
3. Nasal flaring
4. Respiratory rate of 40 during sleep
5. Chest retractions

Page Ref: 815

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

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 the nursing care required.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate?
2. Delivery of the neonate on its side with head up, to facilitate drainage of secretions.
3. Direct tracheal suctioning by specially trained personnel.
4. Preparation for the immediate use of positive pressure to expand the lungs.
5. Suctioning of the oropharynx when the newborn's head is delivered.

Page Ref: 808

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | 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 the nursing care required.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition?
2. Meconium aspiration syndrome
3. Transient tachypnea of the newborn
4. Respiratory distress syndrome
5. Prematurity of the neonate

Page Ref: 816

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

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 the nursing care required.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (R D S). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment?
2. Decreased urine output
3. Pulmonary vascular resistance increases
4. Increased P C O2
5. Increased urination

Page Ref: 815

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

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 the nursing care required.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn?
2. Jitteriness
3. Sucking on fingers
4. Lusty cry
5. Axillary temperature of 98°F

Page Ref: 828

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do?
2. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood.
3. Use a previous puncture site.
4. Cool the heel prior to obtaining blood.
5. Use a sterile needle and aspirate.

Page Ref: 829

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 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. | A A C N 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. | N L N Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?
2. Increased skin temperature and respirations
3. Blood glucose level of 45
4. Room-temperature I V running
5. Positioned under radiant warmer

Page Ref: 827

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Lights can stay on all the time.
2. The eyes do not need to be covered.
3. The lights will need to be removed for feedings.
4. Newborns do not get overheated.
5. Weight loss is not a complication of this system.

Page Ref: 835

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention?
2. Eyes are covered, no clothing on, diaper in place
3. Axillary temperature 99.7°F
4. Infant removed from the isolette for breastfeeding
5. Loose bowel movement

Page Ref: 835

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Physiologic jaundice occurs after 24 hours of age.
2. Pathologic jaundice occurs after 24 hours of age.
3. Phototherapy increases serum bilirubin levels.
4. The need for phototherapy depends on the bilirubin level and age of the infant.
5. Kernicterus causes irreversible neurological damage.

Page Ref: 831

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 4 Differentiate between physiologic and pathologic jaundice according to timing of onset (age in hours), etiology, possible sequelae, and specific management.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 m g/d L to 16.6 m g/d L in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn?
2. Continue to observe
3. Begin phototherapy
4. Begin blood exchange transfusion
5. Stop breastfeeding

Page Ref: 832

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 4 Differentiate between physiologic and pathologic jaundice according to timing of onset (age in hours), etiology, possible sequelae, and specific management.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The client with blood type O R h-negative has given birth to an infant with blood type O R h-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse?
2. "The R h o G A M you received at 28 weeks' gestation did not prevent alloimmunization."
3. "Your body has made antibodies against the baby's blood that are destroying her red blood cells."
4. "The red blood cells of your baby are breaking down because you both have type O blood."
5. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

Page Ref: 831

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Explain how R h incompatibility or A B O incompatibility can lead to the development of hyperbilirubinemia.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. Which of the following are considered risk factors for development of severe hyperbilirubinemia?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Northern European descent
2. Previous sibling received phototherapy
3. Gestational age 27 to 30 weeks
4. Exclusive breastfeeding
5. Infection

Page Ref: 832

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 5 Explain how R h incompatibility or A B O incompatibility can lead to the development of hyperbilirubinemia.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. A newborn is receiving phototherapy. Which intervention by the nurse would be most important?
2. Measurement of head circumference
3. Encouraging the mother to stop breastfeeding
4. Stool blood testing
5. Assessment of hydration status

Page Ref: 835

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is observing a student nurse who is caring for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care?
2. Urine specific gravity is assessed at each voiding.
3. Eye coverings are left off to help keep the baby calm.
4. Temperature is checked every 6 hours.
5. The infant is taken out of the isolette for diaper changes.

Page Ref: 846

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. C. 2. Appreciate the cognitive and physical limits of human performance. | A A C N Essentials Competencies: Ⅸ. 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver's knowledge of care requirements to promote safe care. | N L N Competencies: Quality and Safety: Stay current in professional healthcare knowledge. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy?
2. The newborn maintains a normal temperature
3. An increase of serum bilirubin levels
4. Weight loss
5. Skin blanching yellow

Page Ref: 835

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Increased pulse
2. High blood pressure
3. Tachycardia
4. Bradycardia
5. Capillary filling time greater than 3 seconds

Page Ref: 840

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Explain the etiology and the nursing care of newborns with anemia.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. Mild or chronic anemia in an infant may be treated adequately by which of the following?
2. Transfusions with O-negative or typed and cross-matched packed red cells
3. Iron supplements or iron-fortified formulas
4. Steroid therapy
5. Antibiotics or antivirals

Page Ref: 840

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 7 Explain the etiology and the nursing care of newborns with anemia.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. What indications would lead the nurse to suspect sepsis in a newborn?
2. Respiratory distress syndrome developing 48 hours after birth
3. Temperature drops from 97.4°F to 97.0 2°F hours after 2 hours of warming.
4. Irritability and flushing of the skin at 8 hours of age
5. Bradycardia and tachypnea developing when the infant is 36 hours old

Page Ref: 845

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 8 Describe the clinical manifestations that would lead the nurse to suspect newborn sepsis.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Obtain skin cultures.
2. Restrict parental visits.
3. Evaluate bilirubin levels.
4. Administer oxygen as ordered.
5. Observe for signs of hypoglycemia.

Page Ref: 846

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 9 Delineate the nursing care of the newborn with an infection.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best?
2. "I'll bring you to your baby and then leave so you can have some privacy."
3. "Your baby is on a ventilator with 50% oxygen, and has an umbilical line."
4. "I am so sorry this has all happened. I know how stressful this can be."
5. "Your baby is working hard to breathe and lying quite still, and has an I V."

Page Ref: 849

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Safety and Infection Control

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 11 Describe interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following?
2. A history of obsessive-compulsive disorder (O C D)
3. Chlamydia
4. Delivered six other children by cesarean section
5. A urinary tract infection (U T I)

Page Ref: 843

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (H S V or C M V), and chlamydia, to the management of the newborn in the neonatal period.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate?
2. Meticulous hand washing and antibiotic eye ointment administration.
3. Intravenous acyclovir (Zovirax) and contact precautions.
4. Cultures of blood and C S F and serial chest x-rays every 12 hours.
5. Parental rooming-in and four intramuscular injections of penicillin.

Page Ref: 842

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N 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. | N L N Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (H S V or C M V), and chlamydia, to the management of the newborn in the neonatal period.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The parents of a preterm newborn wish to visit their baby in the N I C U. A statement by the nurse that would not support the parents as they visit their newborn is which of the following?
2. "Your newborn likes to be touched."
3. "Stroking the newborn will help with stimulation."
4. "Visits must be scheduled between feedings."
5. "Your baby loves her pink blanket."

Page Ref: 849

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Communication

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 11 Describe interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected?
2. "If I had taken better care of myself, this wouldn't have happened."
3. "I've been sleeping very well since I had the baby."
4. "This is probably the doctor's fault."
5. "If I hadn't seen our baby's birth, I wouldn't believe she is ours."

Page Ref: 835

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 9 Delineate the nursing care of the newborn with an infection.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. An infant with a pneumothorax has the following chest x-ray result. Which area should the nurse identify as being the pneumothorax?

1. A
2. B
3. C
4. D

Page Ref: 824

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

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 the nursing care required.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse is preparing to measure a newborn's blood glucose level. Which areas on wthe heel should be used to obtain a blood sample for this test?

1. A
2. B
3. C
4. D
5. E

Page Ref: 829

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process.

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress, asphyxia, and hypoglycemia), the effects on the newborn, and the nursing implications.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. The nurse sees the following patient in the neonatal intensive care unit and realizes that additional care will need to be provided for which health problem?

1. Hypotension
2. Hypoglycemia
3. Hyperglycemia
4. Hyperbilirubinemia

Page Ref: 835

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N 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. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process.

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.

1. A neonate weighing 5.5 l b is prescribed to receive intravenous cefotaxime (Claforan) 50 m g/k g/dose every 6 hours for treatment of sepsis. How many m g of the medication should the nurse anticipate the patient will need for 24 hours? (Calculate to the nearest whole number.)

Page Ref: 845

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process.

Learning Outcome: 9 Delineate the nursing care of the newborn with an infection.

M N L L O: Demonstrate understanding of birth-related stressors that place the newborn at risk.