Chapter 17: High-Risk Neonatal Nursing Care (Actual Exam) Latest Update 2025 (Correct Answ, Exams of Nursing

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1. 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 Answers ✅ANS: a a. Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight. b. Neonates with birth weight less than 1500 grams but greater than 1000 grams are classified as very low birth weight. c. Neonates with birth weight less than 1000 grams are classified as extremely low birth weight. d. Neonates born less than 32 weeks' gestation are classified as very premature.
2. 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:

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a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC) - Correct Answers ✅ANS: d a. Assessment findings for RDS include tachypnea, intercostal retractions, respiratory grunting, and nasal flaring. b. Assessment findings for BPD include chest retractions; audible wheezing, rales, and rhonchi; hypoxia; and bronchospasm. c. Assessment findings for PVH include bradycardia, hypotonia, full and/or tense anterior fontanel, and hyperglycemia. d. 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.

3. 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?

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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 Answers ✅ANS: c a. Correct information, but does not fully address the woman's concern. b. Correct, but GBS is not a sexually transmitted disease. c. Correct. This response answers her questions and allows her to ask additional questions about her baby's health. d. Acknowledges that she is upset but does not provide immediate information.

5. 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? a. Hypoglycemia b. Hypercalcemia

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c. Cold stress d. Neonatal withdrawal - Correct Answers ✅ANS: d a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability, apnea, lethargy, and temperature instability, but not nasal congestion. b. Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac arrhythmias. c. Signs and symptoms of cold stress are decreased temperature, cool skin, lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting. d. These are common signs and symptoms of neonatal withdrawal.

6. The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible? a. 1-day-old, HR 170 bpm, crying b. 2-day-old, T 98.9°F, slightly jaundice c. 3-day-old, breastfeeding q 2 h, rooting d. 4-day-old, RR 70 rpm, dusky coloring - Correct Answers ✅ANS: d a. A slight tachycardia—170 bpm—is normal when a baby is crying.

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c. This is an appropriate suggestion. Encouraging parents to spend time with their baby and hold their baby is an action that supports the parents during the grieving process. d. This is an inappropriate suggestion. It is very important for the parents to clearly communicate the baby's death with their other children.

8. The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? a. Intermittent strabismus b. Startling c. Grunting d. Vaginal bleeding - Correct Answers ✅ANS: c a. Pseudostrabismus is a normal finding. b. Startling is a normal finding. c. Grunting is a sign of respiratory distress. The neonatologist should be notified. d. Vaginal bleeding is a normal finding.

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9. It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time? a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation. d. Stimulate the baby to cry. - Correct Answers ✅ANS: c a. This action is not appropriate. The baby needs tracheal suctioning. b. The baby needs to have tracheal suctioning. The most important action to promote health for the baby is for the health-care team to establish an airway that is free of meconium. c. This action is appropriate. The baby needs to be intubated in order for deep suctioning to be performed by the physician. A nurse would not intubate and suction but rather would assist with the procedures. d. It is strictly contraindicated to stimulate the baby to cry until the trachea has been suctioned. The baby would aspirate the meconium-stained fluid, which could result in meconium-aspiration syndrome.

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b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash - Correct Answers ✅ANS: c a. Babies who are withdrawing from drugs have disorganized behavioral states and sleep very poorly. b. There is nothing in the scenario that indicates that this child is hypovolemic or anemic. c. Babies who are experiencing withdrawal often experience bouts of diarrhea. d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.

12. 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

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d. Hydrocele - Correct Answers ✅ANS: a a. This infant is high risk for respiratory distress. The nurse should observe this baby carefully for grunting. b. Acrocyanosis is a normal finding. c. Pseudostrabismus is a normal finding. d. Hydrocele should be reported to the neonatologist. It is not, however, an emergent problem, and it is not related to group B streptococci colonization in the mother.

13. 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 Answers ✅ANS: a a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature.

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15. 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 Answers ✅ANS: a a. A preterm infant is an infant with gestational age of fewer than 36 completed weeks. b. Term births are infants born between 37 and 40 weeks. c. SAG infants at 36 weeks weigh less than 2000 grams. d. LAG infants at 36 weeks weigh over 3400 grams.
16. The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: a. Lecithin b. Calcium c. Surfactant

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d. Magnesium - Correct Answers ✅ANS: c a. The ratio of lecithin to sphingomyelin in the amniotic fluid is used to assess maturity of fetal lungs. b. Calcium is needed to prevent undermineralization of bones. c. 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. d. Magnesium is needed to prevent undermineralization of bones.

17. 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."

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(RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.) a. Exogenous surfactant b. Corticosteroids c. Continuous positive airway pressure (CPAP) d. Bronchodilators - Correct Answers ✅ANS: a, c a. This is a common medical treatment for RDS. b. Corticosteroids are given to women in preterm labor to decrease the risk of RDS. c. CPAP is used to assist neonates with RDS. d. Bronchodilators are given to neonates with bronchopulmonary dysplasia (BPD).

19. Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates? (Select all that apply.) a. Early oral feedings with formula b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia

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d. Nasogastic feedings - Correct Answers ✅ANS: a, d a. Preterm neonates have a decreased ability to digest and absorb formula. Undigested formula can cause a blockage in the intestines leading to necrosis of the bowel. b. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. c. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. d. Bacterial colonization in the intestines can occur from contaminated feeding tubes causing an inflammatory response in the bowel.

20. Nursing actions that decrease the risk of skin breakdown include which of the following? (Select all that apply.) a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings d. Drying thoroughly - Correct Answers ✅ANS: a, b, c

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c. A decrease in environmental temperature leads to a decrease in the neonate's body temperature which leads to an increase in respiratory and heart rate that leads to an increase in oxygen consumption. d. Clustering of nursing care decreases stress which decreases oxygen requirements.

22. A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance? (Select all that apply.) a. Check for presence of bowel sounds b. Assess temperature c. Check gastric residual by aspirating stomach contents d. Assess stools - Correct Answers ✅ANS: a, c, d a. Feedings should be held and physician notified if bowel sounds are absent. b. The neonate's temperature has no direct effect on feeding tolerance. c. Aspirated stomach contents are assessed for amount, color, and consistency. This assists in the evaluation of the degree of digestion and absorption.

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d. Stools are assessed for consistency, amount, and frequency. This assists in the evaluation of the degree of digestion and absorption.

23. 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 Answers ✅ANS: a, b, c, d a. 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. b. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. 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