ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 8 : Health Problems of Newborns Questions
Question 1 of 5
What is an important nursing intervention for a full-term infant receiving phototherapy?
Correct Answer: A
Rationale: Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a frying effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breastfeeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.
Question 2 of 5
Rh hemolytic disease is suspected in a mothers second baby, a son. Which factor is important in understanding how this could develop?
Correct Answer: B
Rationale: Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell (RB
C) destruction. The major causes of this are maternal-fetal Rh and ABO incompatibility. If an Rh-negative mother has previously been exposed to Rh-positive blood through pregnancy or blood transfusion, antibodies to this blood group antigen may develop so that she is isoimmunized. With further exposure to Rh-positive blood, the maternal antibodies agglutinate with the RBCs of the fetus that has the antigen and destroy the cells. Hemolytic disease caused by ABO incompatibilities can be present with the first pregnancy. The gender of the first child is not a concern. Blood type is the important consideration. If both parents have type O blood, ABO incompatibility should not be a possibility.
Question 3 of 5
When should the nurse expect jaundice to be present in a full-term infant with hemolytic disease?
Correct Answer: B
Rationale: In hemolytic disease of the infant, jaundice is usually evident within the first 24 hours of life. Infants with hemolytic disease are usually not jaundiced at birth, although some degree of hepatosplenomegaly, pallor, and hypovolemic shock may occur when the most severe form, hydrops fetalis, is present. Twenty-five to 72 hours after birth is too late for hemolytic disease of the infant. Jaundice at these ages is most likely caused by physiologic or early-onset breastfeeding jaundice.
Question 4 of 5
A woman who is Rh-negative is pregnant with her first child, and her husband is Rh positive. During her 12-week prenatal visit, she tells the nurse that she has been told that this is dangerous. What should the nurse tell her?
Correct Answer: D
Rationale: The goal is to prevent isoimmunization. If the mother has not been previously exposed to the Rh-negative antigen, Rh immunoglobulin (RhIg) is administered at 26 to 28 weeks of gestation and again within 72 hours of birth. The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the infant secondary to the Rh factor. Unless other problems coexist, the newborn will not require transfusions at birth.
Question 5 of 5
The nurse is planning care for an infant receiving calcium gluconate for treatment of hypocalcemia. Which route of administration should be used?
Correct Answer: C
Rationale: Calcium gluconate is administered intravenously over 10 to 30 minutes or as a continuous infusion. If it is given more rapidly than this, cardiac dysrhythmias and circulatory collapse may occur. Early feedings are indicated, but when the ionized calcium drops below 3.0 to 4.4 mg/dL, intravenous calcium gluconate is necessary. Intramuscular or intraosseous administration is not recommended.