Assessment and management of high risk and sick newborn
Time: 15:00
A preterm infant is born at 30 weeks gestation. What is the nurse's highest priority action in the delivery room?
[a] Obtaining a footprint for the medical record.
[b] Administering the initial dose of Hepatitis B vaccine.
[c] Placing the infant under a radiant warmer and drying them thoroughly.
[d] Measuring the infant's head circumference and length.
The nurse is assessing a preterm neonate with Respiratory Distress Syndrome (RDS). Which finding is a classic sign of this condition?
[a] A slow, deep respiratory pattern.
[b] A loud, vigorous cry.
[c] Expiratory grunting and nasal flaring.
[d] Pink, moist mucous membranes.
When providing care for a jaundiced newborn receiving phototherapy, which nursing intervention is essential?
[a] Applying lotion to the infant's skin to prevent drying.
[b] Dressing the infant in a full sleeper to maintain warmth.
[c] Limiting fluid intake to concentrate the bilirubin.
[d] Placing opaque eye shields over the infant's closed eyes.
Which newborn is at the highest risk for developing hypoglycemia?
[a] A full-term infant who is breastfeeding well.
[b] A large-for-gestational-age (LGA) infant of a diabetic mother.
[c] An infant with physiological jaundice.
[d] An infant with a caput succedaneum.
A nurse is assessing a 2-day-old infant. Which of the following is a subtle but significant sign of neonatal sepsis?
[a] A vigorous cry and active movement.
[b] A heart rate of 140 beats per minute.
[c] Lethargy and poor feeding.
[d] A stable body temperature.
The primary cause of Respiratory Distress Syndrome (RDS) in preterm infants is:
[a] Aspiration of meconium in utero.
[b] A bacterial or viral infection.
[c] The presence of a congenital heart defect.
[d] A deficiency of pulmonary surfactant.
Which finding would differentiate pathological jaundice from physiological jaundice in a newborn?
[a] Jaundice that appears on the third day of life.
[b] A total serum bilirubin level of 8 mg/dL on day four.
[c] Jaundice that is visible within the first 24 hours of life.
[d] Jaundice that is limited to the face and sclera.
The nurse's immediate action for a preterm infant experiencing an apneic spell should be to:
[a] Administer a bolus of IV fluids.
[b] Notify the physician immediately.
[c] Increase the oxygen concentration.
[d] Provide gentle tactile stimulation.
A preterm infant in the NICU develops abdominal distension, feeding intolerance, and has a guaiac-positive (bloody) stool. The nurse should suspect which serious condition?
[a] Respiratory Distress Syndrome (RDS).
[b] Necrotizing enterocolitis (NEC).
[c] Neonatal sepsis.
[d] Intraventricular hemorrhage (IVH).
A newborn loses heat by evaporation when the nurse:
[a] Places the infant on a cold scale.
[b] Leaves the infant near a drafty window.
[c] Fails to dry the infant completely after a bath.
[d] Places the infant in a bassinet next to a cool wall.
Gavage feeding is used for preterm infants primarily because of their:
[a] High caloric needs.
[b] Inability to digest formula.
[c] Poorly coordinated suck, swallow, and breathing reflexes.
[d] Small stomach capacity.
A common sign of cold stress in a newborn is:
[a] Shivering and a flushed appearance.
[b] A hyperactive, irritable state.
[c] Respiratory distress and hypoglycemia.
[d] A stable heart rate and blood pressure.
Which assessment is a key indicator of meconium aspiration syndrome (MAS) in a newborn at birth?
[a] A high-pitched, shrill cry.
[b] Generalized edema.
[c] Respiratory distress in an infant born through meconium-stained amniotic fluid.
[d] The absence of primitive reflexes.
A newborn exhibits jitteriness, a high-pitched cry, and poor feeding. The nurse's first action should be to:
[a] Swaddle the infant tightly.
[b] Offer a pacifier.
[c] Check the infant's blood glucose level.
[d] Assess the infant's temperature.
When caring for an infant with Neonatal Abstinence Syndrome (NAS) due to maternal opioid use, the nurse should prioritize which intervention?
[a] Providing frequent auditory and visual stimulation.
[b] Encouraging frequent handling by multiple caregivers.
[c] Swaddling the infant snugly and providing a low-stimulus environment.
[d] Placing the infant in a room near the nurses' station.
The Silverman-Andersen Index is a tool used to assess the severity of:
[a] Neonatal jaundice.
[b] Neurological impairment.
[c] Drug withdrawal.
[d] Respiratory distress.
Which assessment finding distinguishes a cephalohematoma from a caput succedaneum?
[a] It is present at birth.
[b] It is a soft, spongy swelling.
[c] It does not cross the cranial suture lines.
[d] It typically resolves within 24-48 hours.
A high-risk infant is defined as one who:
[a] Weighs more than 4000 grams at birth.
[b] Has a high probability of morbidity or mortality due to prenatal, perinatal, or postnatal conditions.
[c] Is born to a mother over the age of 30.
[d] Cries excessively in the first 24 hours of life.
A newborn with a diagnosis of transient tachypnea of the newborn (TTN) is likely to show which clinical course?
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