Michael McDonald 11/06/11
5 Signs and Symptoms of Increased Intracranial Pressure (Earliest to Latest):
1. A change or decrease in Level of Consciousness
a) disorientation
b) behavior changes (restlessness, irritability.)
2. Headache
3. Nausea and Vomiting.
4. Change in speech pattern
5. Pupillary changes
a) dilated and nonreactive
b) constricted and nonreactive
3 Positions Contraindicated in a patient with Increased ICP
1. HOB higher than 30°
2. Extreme hip and neck flexion
3. Trendelenberg position
15 NCLEX questions relating to infants in NICU
1. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?
a. Turn the neonate every 6 hours
b. Encourage the mother to discontinue breast-feeding
c. Notify the physician if the skin becomes bronze in color
d. Check the vital signs every 2 to 4 hours (Correct answer)
2. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?
a. Startle reflex (correct answer)
b. Babinski reflex
c. Grasping reflex
d. Tonic neck reflex
3.Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?
a. Low room humidity
b. Cold weight scale
c. Cools incubator walls (correct answer)
d. Cool room temperature
4.When administering an I.M. injection to an infant, the nurse in charge should use which site?
a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Vastus lateralis (correct answer)
5.Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?
a. A sunken fontanel (correct answer)
b. Decreased pulse rate
c. Increased blood pressure
d. Low urine specific gravity
6. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?
a. Measuring head circumference (correct answer)
b. Obtaining skull X-ray
c. Performing a lumbar puncture
d. Magnetic resonance imaging (MRI)
7. A nurse is caring for a small-for-gestational-age (SGA) neonate. What complication is this baby at risk for?
a) Polycythemia (correct answer)
b) Hyperglycemia
c) Seizures
d) Hyperviscosity
8. A nurse is caring for a high-risk 4-hour-old neonate. The neonate was born at 36 weeks' gestation. What is the newborn's classification?
a) Post-term newborn
b) Preterm newborn (correct answer)
c) Term newborn
d) Small-for-gestational-age (SGA) newborn
9. A nurse is caring for a two-hour-old infant of a diabetic mother. How frequently should the nurse monitor the infant's blood glucose level?
a) Every hour (correct answer)
b) Every two hours
c) Every four hours
d) Once a shift
10. A nurse is caring for an infant who was exposed to alcohol in utero. What characteristic(s) might this baby exhibit?
a) Rhinorrhea and genital candidiasis
b) Cyanosis
c) Hypertonicity and Jitteriness
d) Microcephaly and facial abnormalities(correct answer)
11. A nurse is bottle-feeding a 34-week-gestation neonate. How long should the feeding last?
a) 5-10 minutes
b) 10-15 minutes
c) 15-20 minutes (correct answer)
d) 20-30 minutes
12. A 32-week-gestation neonate in the neonatal intensive care unit is being fed intravenously. How often should the nurse change the IV solutions and tubing
a) Every feeding
b) Every eight hours
c) Every shift
d) Every 24 hours (correct answer)
13. A nurse is caring for a 37-week-gestation neonate who frequently sneezes, hiccups and yawns, has poor feeding and diarrhea, has mild tremors when stimulated, and with respiration of 70 breaths per minute when quiet. These clinical manifestations are typical of which condition?
a) None
b) Newborn withdrawal or neonatal abstinence syndrome (correct answer)
c) Fetal Alcohol Syndrome
d) Infant of a Diabetic Mother
14. An HIV positive mother asks the nurse, "How soon can I know if my baby has HIV?" What is the correct response by the nurse?
a) "We should know within 24 hours after birth using the PCR test." (correct answer)
b) "It takes about six months before your baby will develop symptoms."
c) "At birth, we will take a sample of the umbilical cord blood to test for the virus."
d) “Current serologic tests cannot differentiate between your blood and your baby's blood for 15 months.”
15. A nurse is teaching new parents about the recommended genetic screening tests available for babies prior to discharge. These screening programs test for disorders associated with which of the following?
a) Mental Retardation (correct answer)
b) Cardiac Anomalies
c) Neural Tube defects
d) Congenital anomalies
Questions 1-6 from : http://nclexreviewers.com/
Questions 7-15 from : http://wps.prenhall.com/chet_olds_maternal_7/11/2965/759237.cw/index.html
5 Signs and Symptoms of Increased Intracranial Pressure (Earliest to Latest):
1. A change or decrease in Level of Consciousness
a) disorientation
b) behavior changes (restlessness, irritability.)
2. Headache
3. Nausea and Vomiting.
4. Change in speech pattern
5. Pupillary changes
a) dilated and nonreactive
b) constricted and nonreactive
3 Positions Contraindicated in a patient with Increased ICP
1. HOB higher than 30°
2. Extreme hip and neck flexion
3. Trendelenberg position
15 NCLEX questions relating to infants in NICU
1. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?
a. Turn the neonate every 6 hours
b. Encourage the mother to discontinue breast-feeding
c. Notify the physician if the skin becomes bronze in color
d. Check the vital signs every 2 to 4 hours (Correct answer)
2. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?
a. Startle reflex (correct answer)
b. Babinski reflex
c. Grasping reflex
d. Tonic neck reflex
3.Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?
a. Low room humidity
b. Cold weight scale
c. Cools incubator walls (correct answer)
d. Cool room temperature
4.When administering an I.M. injection to an infant, the nurse in charge should use which site?
a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Vastus lateralis (correct answer)
5.Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?
a. A sunken fontanel (correct answer)
b. Decreased pulse rate
c. Increased blood pressure
d. Low urine specific gravity
6. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?
a. Measuring head circumference (correct answer)
b. Obtaining skull X-ray
c. Performing a lumbar puncture
d. Magnetic resonance imaging (MRI)
7. A nurse is caring for a small-for-gestational-age (SGA) neonate. What complication is this baby at risk for?
a) Polycythemia (correct answer)
b) Hyperglycemia
c) Seizures
d) Hyperviscosity
8. A nurse is caring for a high-risk 4-hour-old neonate. The neonate was born at 36 weeks' gestation. What is the newborn's classification?
a) Post-term newborn
b) Preterm newborn (correct answer)
c) Term newborn
d) Small-for-gestational-age (SGA) newborn
9. A nurse is caring for a two-hour-old infant of a diabetic mother. How frequently should the nurse monitor the infant's blood glucose level?
a) Every hour (correct answer)
b) Every two hours
c) Every four hours
d) Once a shift
10. A nurse is caring for an infant who was exposed to alcohol in utero. What characteristic(s) might this baby exhibit?
a) Rhinorrhea and genital candidiasis
b) Cyanosis
c) Hypertonicity and Jitteriness
d) Microcephaly and facial abnormalities(correct answer)
11. A nurse is bottle-feeding a 34-week-gestation neonate. How long should the feeding last?
a) 5-10 minutes
b) 10-15 minutes
c) 15-20 minutes (correct answer)
d) 20-30 minutes
12. A 32-week-gestation neonate in the neonatal intensive care unit is being fed intravenously. How often should the nurse change the IV solutions and tubing
a) Every feeding
b) Every eight hours
c) Every shift
d) Every 24 hours (correct answer)
13. A nurse is caring for a 37-week-gestation neonate who frequently sneezes, hiccups and yawns, has poor feeding and diarrhea, has mild tremors when stimulated, and with respiration of 70 breaths per minute when quiet. These clinical manifestations are typical of which condition?
a) None
b) Newborn withdrawal or neonatal abstinence syndrome (correct answer)
c) Fetal Alcohol Syndrome
d) Infant of a Diabetic Mother
14. An HIV positive mother asks the nurse, "How soon can I know if my baby has HIV?" What is the correct response by the nurse?
a) "We should know within 24 hours after birth using the PCR test." (correct answer)
b) "It takes about six months before your baby will develop symptoms."
c) "At birth, we will take a sample of the umbilical cord blood to test for the virus."
d) “Current serologic tests cannot differentiate between your blood and your baby's blood for 15 months.”
15. A nurse is teaching new parents about the recommended genetic screening tests available for babies prior to discharge. These screening programs test for disorders associated with which of the following?
a) Mental Retardation (correct answer)
b) Cardiac Anomalies
c) Neural Tube defects
d) Congenital anomalies
Questions 1-6 from : http://nclexreviewers.com/
Questions 7-15 from : http://wps.prenhall.com/chet_olds_maternal_7/11/2965/759237.cw/index.html