Nurs 404 Exam 3 (100% correct answers)

Nurs 404 Exam 3 (100% correct answers)
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." 

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