ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 8 : Health Problems of Newborns Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is caring for an infant who will be discharged on home phototherapy. What instructions should the nurse include in the discharge teaching to the parents?
Correct Answer: D
Rationale: With short hospital stays, infants may be discharged with a prescription for home phototherapy. It is the responsibility of the nurse planning discharge to include important information such as the need for a follow-up visit with the health care provider in 2 or 3 days to evaluate feeding and elimination pattern and to have blood work done if needed. The parents should be taught to not apply oil or lotions to prevent increased tanning; the babys eye shields can come off when the phototherapy lights are turned off, and the infants temperature needs to be monitored but not taken every 2 hours.
Question 5 of 5
The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery. The infants blood glucose level is 36 mg/dL. Which action should the nurse implement?
Correct Answer: A
Rationale: A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic, as indicated by a blood glucose level of 36 mg/dL, and who is clinically asymptomatic should probably reestablish normoglycemia with early institution of breast or bottle feeding. The newborn does not require a nasogastric tube and 5% dextrose water or a peripheral intravenous line with 10% dextrose because the blood glucose level is only borderline. The infant does need to be monitored, but breastfeeding should be started and the blood glucose level checked in 1 to 2 hours.