Exam 3 NUR 404 | Questions, Answers and Rationales
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Course
NUR 404
Institution
NUR 404
Exam 3 NUR 404 | Questions, Answers and Rationales A nurse is assessing a premature newborn and notes an episode of apnea lasting 25 seconds, accompanied by bradycardia. What is the priority nursing intervention? A. Notify the physician immediately. B. Administer oxygen via nasal cannula. C. Pro...
A nurse is assessing a premature newborn and notes an episode of apnea lasting 25
seconds, accompanied by bradycardia. What is the priority nursing intervention?
A. Notify the physician immediately.
B. Administer oxygen via nasal cannula.
C. Provide gentle tactile stimulation to the infant.
D. Place the infant in a prone position to facilitate breathing.
Rationale: Tactile stimulation can often prompt the infant to breathe again.
Which of the following statements about apnea in newborns is true?
A. Apnea episodes in newborns are typically self-resolving without intervention.
B. A full stomach can enhance the risk of apnea by applying pressure to the diaphragm.
C. All newborns should be placed on respiratory support after an apneic episode.
D. Apnea monitors are primarily used for detecting bradycardia in infants.
Rationale: Many episodes may resolve spontaneously; however, monitoring and gentle
stimulation are critical.
A nurse is educating parents about managing apnea in their premature infant. Which
instruction is most important to include?
A. Allow the infant to sleep on their stomach to prevent apnea.
B. Provide tactile stimulation only if the infant appears to be in distress.
C. Maintain a neutral thermal environment to help prevent apnea episodes.
D. Frequent feedings will help the infant gain weight and reduce apnea.
Rationale: A neutral thermal environment is crucial for reducing fatigue and preventing
apnea.
When monitoring a newborn for apnea, which finding would indicate the need for
immediate intervention?
A. The infant is occasionally still for 15 seconds during sleep.
B. The infant's heart rate drops to 80 beats per minute during an apneic episode.
C. The infant demonstrates rhythmic breathing interspersed with short pauses.
D. The infant exhibits a bluish tint to the lips during an apneic episode.
,Rationale: Assessing the infant is the first step in determining the need for further
intervention.
A nurse is caring for a newborn who has just been resuscitated. The infant exhibits
signs of hypoglycemia. What is the most appropriate nursing action?
A. Administer intravenous fluids with dextrose as prescribed.
B. Encourage oral feeding immediately to boost blood sugar levels
C. Monitor the infant's blood pressure closely for changes.
D. Document the findings and continue to observe the infant.
Rationale: Immediate treatment for hypoglycemia in a newborn typically includes
intravenous dextrose to raise blood sugar levels effectively.
Which assessment finding in a newborn would indicate a need for further evaluation of
fluid status?
A. Urine output of 3 mL/kg/hr.
B. Urine specific gravity of 1.020.
C. Pallor and tachycardia observed during assessment.
D. Consistent feeding pattern with adequate weight gain.
Rationale: Pallor and tachycardia can indicate hypovolemia and inadequate tissue
perfusion, necessitating further evaluation of fluid status.
A newborn presents with signs of tachypnea, decreased arterial blood pressure, and
decreased tissue perfusion. What is the most likely underlying condition?
A. Fetal blood loss due to placenta previa.
B. Hypoglycemia from resuscitation efforts.
C. Infection leading to sepsis.
D. Congenital heart defect affecting circulation.
Rationale: The symptoms described are consistent with hypovolemia, often resulting
from fetal blood loss in conditions like placenta previa.
A nurse is caring for a high-risk newborn who has just undergone resuscitation. Which
intervention is most important to maintain the infant's temperature?
A. Place the newborn under a radiant warmer
B. Dress the infant in multiple layers of clothing.
C. Allow the infant to acclimate to room temperature gradually.
D. Frequently assess the infant's temperature every hour.
Rationale: A radiant warmer provides a controlled environment to maintain the
newborn's temperature, especially after resuscitation.
,A newborn is placed in an environment that is too cold. What physiological response
can be expected in the infant?
A. Increased metabolic rate and vasodilation.
B. Decreased oxygen demand and respiratory rate.
C. Increased metabolic rate and vasoconstriction of peripheral blood vessels.
D. Decreased production of surfactant in the lungs.
Rationale: In a cold environment, the newborn increases metabolism to generate heat,
leading to vasoconstriction to conserve body heat.
Which of the following statements made by a nursing student regarding
thermoregulation in high-risk newborns indicates a need for further education?
A. "Keeping the newborn in a neutral-temperature environment minimizes metabolic
demand."
B. "If the environment is too hot, the infant's metabolism decreases to cool the body."
C. "Prolonged cold exposure can lead to metabolic acidosis due to anaerobic
glycolysis."
D. "High temperatures prevent the ductus arteriosus from remaining open."
Rationale: High temperatures can increase metabolic demand, not prevent the ductus
arteriosus from remaining open; it's the hypoxia and low PO2 that may keep it open.
A high-risk newborn is experiencing hypoxia due to respiratory difficulty. Which
compensatory mechanism is the infant likely to exhibit?
A. Peripheral vasodilation to increase blood flow.
B. Increased cardiac output to enhance oxygen delivery.
C. Shunting of blood away from peripheral tissues toward vital organs.
D. Decreased respiratory rate to conserve energy.
Rationale: To prioritize oxygen delivery to essential body functions, the body shunts
blood to the central torso, reducing perfusion to peripheral tissues.
A nurse is assessing a high-risk newborn who has been in a cold environment for an
extended period. Which laboratory finding would most likely indicate the consequence
of prolonged cold exposure?
A. Elevated PO2 levels and decreased PCO2 levels.
B. Increased arterial blood pH and decreased bicarbonate levels.
C. Decreased PO2 levels and increased lactic acid in the blood.
D. Normal blood glucose levels and elevated respiratory rate.
Rationale: Prolonged cold exposure leads to increased metabolism and anaerobic
glycolysis, resulting in hypoxia (lowered PO2) and lactic acid accumulation.
, A nurse is caring for a newborn who experienced severe asphyxia at birth and is
currently receiving intravenous fluids. What is the most appropriate nursing action if the
infant's respiratory rate remains rapid and ineffective for sucking?
A. Encourage oral feedings with breast milk.
B. Initiate gavage feedings using expressed breast milk.
C. Delay all feeding until respiratory status improves.
D. Consult a dietitian for specialized nutritional needs.
Rationale: Gavage feedings can provide necessary nutrition when the infant cannot
suck effectively due to respiratory distress.
A premature neonate is showing signs of hunger, such as rooting and sucking motions.
Which feeding method should the nurse prioritize to provide optimal nutrition?
A. Formula feeding through a bottle.
B. Gavage feeding with expressed breast milk.
C. Total parenteral nutrition (TPN).
D. Gastrostomy tube feeding.
Rationale: Breast milk offers immune protection and optimal nutrients, making it the best
choice for premature infants, especially in a gavage feeding situation.
What is a key benefit of offering oral stimulation, such as a pacifier, to a neonate
receiving gavage or gastrostomy feedings?
A. It decreases the need for intravenous fluids.
B. It helps the infant develop proper sucking reflexes.
C. It ensures adequate caloric intake.
D. It prevents the risk of aspiration during feeding.
Rationale: Oral stimulation promotes the development of the sucking reflex, which can
aid in transitioning to oral feedings later.
Which of the following statements regarding the feeding of premature neonates is
accurate?
A. Premature neonates do not require breast milk since formula is nutritionally superior.
B. Gavage feeding should only be used for infants who are unable to suck due to
congenital anomalies.
C. Expressed breast milk can be utilized in gavage feeding to provide optimal nutrition.
D. Oral stimulation is unnecessary for infants who are being fed via gastrostomy tube.
Rationale: Using expressed breast milk in gavage feeding offers the nutritional benefits
of breast milk to premature infants.
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