Question 5421)
A baby boy was born at 2:45 A.M. after a 35-week gestation. He weighed 1170 g.
Upon admission to the premature nursery, he had slight respiratory distress, nasal flaring,
grunting, intercostal retractions, and slight cyanosis. Apgar score at one minute was 4, and at five
minutes, it was 6. Apical pulse is 164, respirations are 44, and axillary temperature is 96°F. What
was the most likely cause of the baby’s cyanosis?
A. Increased serum concentration of bilirubin
B. Inadequate oxygenation of arterial blood
C. Excessive number of red blood cells
D. Lack of subcutaneous fatty tissue
Answer: B
Explanation: Cyanosis is indicative of inadequate oxygenation. Increased bilirubin would be evidenced by jaundice.
It is normal for newborns to have excessive red blood cells. This does not cause cyanosis. Lack of subcutaneous
fatty tissue is common in premature infants and causes poor temperature regulation.
Question 5422)
When assessing a newborn’s need for oxygen, which of the following should the
nurse assess because it is the best indicator?
A. Respiratory rate
B. Skin color
C. Pulse rate
D. Arterial pO2
Answer: D
Explanation: Arterial pO2 is the best indicator of oxygen levels. Respiratory rate, skin color, and pulse rate can be
affected by factors other than oxygenation. They are indicators but are not the most reliable.
Question 5423)
On the evening of the second day after birth, the nurse notes that an infant
appears icteric. What is the most likely cause?
A. Rupture of a great number of fragile red cells in a short period of time
B. Inflammatory obstruction of hepatic bile ducts and resorption of pigments
C. Extravasation of blood from ruptured capillaries into subcutaneous tissue
D. Faulty melanin metabolism due to absence of enzymes for normal protein synthesis
Answer: A
Explanation: Red blood cells of premature infants are fragile and break down rapidly, causing an increase in
bilirubin, which causes icterus or jaundice. The timing is key. Jaundice occurring after 49 hours is usually
physiological jaundice. Jaundice presenting at birth or within the first 24 hours is usually pathological in nature.
Obstruction of hepatic bile ducts would be a pathological cause of jaundice and would occur earlier. Answer 3 is
not realistic. This might cause a bruising appearance but not jaundice. Answer 4 makes no sense.
Question 5424)
On the evening of the second day after birth, an infant was observed to be icteric,
so he was exposed to blue light. What is the purpose of the blue light?
A. To stimulate increased formation of vitamin K in the skin
B. To enhance pigment breakdown by increasing body temperature
C. To convert indirect bilirubin to a less toxic compound
D. To increase brain electrical activity by stimulating the optic nerve
Answer: C
Explanation: The bili light or blue light enhances the breakdown of indirect bilirubin to a less toxic compound.
Vitamin K is not made in the skin; it is made in the intestines. Vitamin D is absorbed by the skin. Increasing
temperature does not enhance pigment breakdown. The eyes are covered when the blue light is used to protect
the eyes against damage.
Question 5425)
A young woman delivered her first baby this morning. She asks the nurse why the
top of the baby’s head is so soft and does not seem to have any bone. What should the nurse
include when responding to the mother?
A. This soft spot is called a fontanel and is normal; it makes delivery easier.
B. It is a condition that occurs in some babies and will disappear within a few days.
C. The physician is monitoring the infant for any problems that might occur with this common defect.
D. It is called caput succedaneum and is caused by bleeding under the scalp during birth.
Answer: A
Explanation: The mother appears to be describing the anterior fontanel, or soft spot, which occurs in all babies.
The skull bones are not completely fused, allowing molding of the head during the birth process. This should close
between 12 and 18 months. It is a normal condition occurring in all babies and is not a defect. Caput succedaneum
is a swelling that may occur on the head following delivery. It crosses suture lines and is due to swelling under the
scalp during birth. It is normal and disappears in a few days. This is not what is described in the question.
Question 5426)
Which finding, if present, would suggest to the nurse that the infant was not at
term when born?
A. The scrotum has rugae
B. Testicles are not descended.
C. Scanty vernix
D. Sparse lanugo
Answer: B
Explanation: Testicles normally descend into the scrotum at eight months gestation. An infant born prior at that
time will have undescended testicles. A term infant will have rugae on the scrotum. Vernix and lanugo are less
with a term infant than with a premature infant.
Question 5427)
The nurse is preparing a 3-day-old infant for discharge from the hospital. When
checking the record for completeness, the nurse checks to see that the infant has had which of
the following?
A. DTP and polio immunizations
B. MMR immunization and tuberculin test
C. Pneumococcal vaccine and HIV test
D. Hepatitis B vaccine and PKU test
Answer: D
Explanation: Hepatitis B vaccine is given within the first 12 hours after birth. A PKU test is done when the infant
has had milk feedings for 24 hours. DTP and polio immunizations are usually started at two months of age. MMR is
given at 15 months. A tuberculin test is usually done at one year. Pneumococcal vaccine is given to infants starting
at two months. Newborns are not routinely tested for HIV.
Question 5428)
The physician has told the parents that their child probably has phenylketonuria.
The parents ask the nurse what special needs the child will have. What should the nurse include in
the response?
A. The baby will most likely not develop normally for longer than six months and will die in a few years.
B. The baby will have a special formula and cannot eat protein foods during childhood.
C. Special feeding techniques are necessary until the child has surgery.
D. The baby will not be able to void normally and will need to be catheterized frequently.
Answer: B
Explanation: Phenylketonuria is a disorder of purine metabolism in which phenylalanine is not metabolized properly
and builds up in the blood and brain and causes severe mental retardation if not treated promptly. The treatment
is to avoid foods containing phenylalanine. The child will have a special formula (Lofenalac) and cannot eat
protein-containing foods. If diagnosed early and if the proper diet is followed, the child should do well. Answer 1 is
more typical of Tay-Sachs disease. Answer 3 is typical of cleft lip or palate.
Question 5429)
A 3-month-old infant is admitted. Upon admission, the nurse assesses her
developmental status as appropriate for age. Which of the following is the child least likely to be
able to do?
A. Smile in response to mother’s face
B. Reach for shiny objects but miss them
C. Hold head erect and steady
D. Sit with slight support
Answer: D
Explanation: Sitting with slight support would be expected in a child of 5 months. All of the other tasks are
appropriate for this age.
Question 5430)
A 3-month-old infant is doing well after the repair of a cleft lip. The nurse wants
to provide the client with appropriate stimulation. What is the best toy for the nurse to provide?
A. Colorful rattle
B. String of large beads
C. Mobile with a music box
D. Teddy bear with button eyes
Answer: C
Explanation: Anything that can be put in the mouth is inappropriate for a child with cleft lip repair. A rattle and
beads can go in the mouth. Button eyes are a hazard for any infant because the infant may swallow them. A mobile
with a music box is appropriate for a 3-month-old who lays in a crib, and this item cannot be put in the mouth.
Note that a colorful rattle is also age appropriate but not condition appropriate.
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