Chapter 13

The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.) a. Paleness b. Transparent skin c. Superficial scalp veins d. Vomiting e. Bulging fontanelles

1. Paleness 2. Vomiting 3. Bulging fontanelles

The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension d. Hyperemesis gravidarum e. Chloasma

1. Placenta previa 2. Gestational diabetes 3. Pregnancy-induced hypertension

Aroma therapy in the NICU is accomplished by (select all that apply) A. placing a sweet-smelling room deodorizer in the room that has a calming effect B. using baby oil on the infant's skin C. placing an article of the mother's clothing in the infant's crib D. using gentle touch to calm the infant

1. placing an article of the mother's clothing in the infant's crib 2. using gentle touch to calm the infant

Which of the following observations of a preterm neonate would indicate the presence of respiratory distress? (select all that apply) A. Substernal retractions B. Respiratory rate of 70/min C. Grunting D. Lethargy

A. Substernal retractions B. Respiratory rate of 70/min C. Grunting

A characteristic sign of necrotizing enterocolitis (NEC) in the newborn is A. blood diarrhea B. necrosis of the abdomen C. projectile vomiting D. high fever

A. blood diarrhea

A mother gives birth to a preterm infant at 30 weeks gestation. When visiting the baby in the intensive care unit, she seems interested in the baby, but sits and watches everything the nurse does for her baby. Which is the most appropriate nursing intervention to promote mother-infant attachment? A. invite her to provide simple care to her infant B. Reassure her that she can hold the baby soon C. stress the importance of frequent visits to the nursery D. demonstrate the skills she will need for home care

A. invite her to provide simple care to her infant

Choose the normal blood glucose level for a preterm infant. A. 28 mg/dL B. 39 mg/dL C. 55 mg/dL D. 150 mg/dL

B. 39 mg/dL

The nurse observes that a preterm infant has a pulse rate of 96 and a pulse oximetry reading of 89%. The FIRST action of the nurse should be A. Go and call the health care provider B. Gently rub the infant's back and suction the nose C. Call a code D. continue observation and documentation as this is normal

B. Gently rub the infant's back and suction the nose

The ideal feeding for most preterm newborns is A. glucose water until the risk for necrotizing enterocolitis diminishes B. breast milk given by suckling, bottle, or gavage C. special commercial formula for preterm babies D. total parenteral nutrition to meet all of the infant's nutritional needs

B. breast milk given by suckling, bottle, or gavage

The alarm on an apnea monitor for a preterm infant sounds. The infant is asleep, the skin color is pink, and the heart rate is 130-135 bpm. The most appropriate initial nursing response is to A. contact the health care provider for orders B. gently rub the infant's back C. give oxygen with an Ambu bag D. suction the infant with a bulb syringe

B. gently rub the infant's back

Which nursing assessment best suggests respiratory distress syndrome? A. Apical heart rate 144/min; bluish hands and feet B. grunting, respiratory rate of 65/min, nasal flaring C. protruding abdomen, irregular respirations D. weak movements, lies with extended posture

B. grunting, respiratory rate of 65/min, nasal flaring

The advantage of radiant warmers in the care of preterm infants is that they A. cannot cause excessive body temperature B. maintain warmth with easy caregiver access C. reduce drying and cracking of the skin D. improve balance of fluids and electrolytes

B. maintain warmth with easy caregiver access

A preterm infant is subject to hypothermia because the A. muscle activity is large related to the calories consumed B. relatively large body surface area allows heat to escape C. sweat glands are overactive, allowing evaporative cooling D. fats stores insulate the infant from radiant heater warmth

B. relatively large body surface area allows heat to escape

An infant is born at 43 weeks' gestation. The nurse should monitor the infant for common problems, such as (select all that apply) A. respiratory distress caused by immature lungs B. increased weight gain resulting from increased glucose availability C. hypoglycemia resulting from reduced glucose reserves D. presence of increased amounts of lanugo

C. hypoglycemia resulting from reduced glucose reserves

An infant is brought to the newborn nursery. The gestation stated on the chart is 39 weeks. The nurse doing the initial assessment notes that the infant has peeling skin and long, thin appearance. What is the probable reason for the infant's appearance? A. the mother did not get adequate nutrients throughout pregnancy B. intrauterine infection depleted subcutaneous fat stores C. the actual gestational age may be greater than 42 weeks D. reduced production of glucose before birth caused weight loss

C. the actual gestational age may be greater than 42 weeks

Gestational age is best determined by A. weight of the infant at birth B. stability of the blood glucose level C. the age at which the infant reaches developmental milestones D. assessment of physical and neurologic characteristics

D. assessment of physical and neurologic characteristics

The nurse must handle the preterm infant gently because capillaries are A. not developed in all areas of the brain B. likely to develop microscopic clots C. sensitive to high levels of clotting factors D. fragile and prone to bleeding spontaneously

D. fragile and prone to bleeding spontaneously

A key nursing intervention to prevent retinopathy of prematurity is to A. provide feedings as early as possible after birth B. perform care to avoid moving the infant more than necessary C. eliminate potential sources of infection from the environment D. monitor the infant's blood oxygen levels

D. monitor the infant's blood oxygen levels

Which physical characteristic should make the nurse an infant's gestational age may be preterm? A. Square window sign assessed at 0 degrees B. small amount of lanugo and vernix present C. labia major cover labia minora of the female D. superficial scalp and abdominal veins easily seen

D. superficial scalp and abdominal veins easily seen

Some preterm infant are fed by gavage because of A. confinement to the incubator B. overdeveloped gag and cough reflexes C. refusal of formula D. weak sucking and swallowing reflexes

D. weak sucking and swallowing reflexes

The mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the nurse's most appropriate response? a. "The placenta does not function adequately as it ages." b. "Infants born postmaturely are generally large." c. "Delivery of the postterm infant is more difficult." d. "There is less amniotic fluid."

a. "The placenta does not function adequately as it ages."

The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant? a. 1 to 3 mL/kg/hr b. 4 to 6 mL/kg/hr c. 7 to 9 mL/kg/hr d. 10 to 14 mL/kg/hr

a. 1 to 3 mL/kg/hr

What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool? a. Assess for abdominal distention. b. Decrease the amount of the next feeding. c. Institute enteric precautions. d. Get a culture of the next stool.

a. Assess for abdominal distention.

The nurse is caring for an infant born at 42 weeks. What would the physical assessment reveal? a. Dry, peeling skin b. Minimal hair on the head c. Short, rough nails d. Abundant lanugo on the body

a. Dry, peeling skin

What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy? a. Monitor arterial oxygen levels with a pulse oximeter. b. Position the head slightly lower than the body. c. Administer low concentrations of oxygen. d. Keep the infant's eyes covered at all times.

a. Monitor arterial oxygen levels with a pulse oximeter.

When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. What do these findings indicate? a. Respiratory distress syndrome b. Postmaturity syndrome c. Apneic episode d. Cold stress

a. Respiratory distress syndrome

The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.) a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemiaa.

a. Seizures b. Asphyxia e. Polycythemia

Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life?a. Weak or absent sucking or swallowing reflex b. Inability to digest food properly c. Refusal to take formula by mouth d. Need for a larger quantity of formula at each feeding

a. Weak or absent sucking or swallowing reflex

The nurse in a pediatrician's office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth? a. 1st b. 2nd c. 3rd d. 4th

b. 2nd

What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate? a. Seizures b. Bradycardia c. Dysrhythmias d. Tetany

b. Bradycardia

How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 8 hours

b. Every 2 hours

The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation? a. Administer oxygen via a nasal cannula. b. Gently rub the infant's feet or back. c. Ventilate with an Ambu bag. d. Perform nasopharyngeal suctioning.

b. Gently rub the infant's feet or back.

What term describes the age of a neonate that is based on the actual time in utero? a. Maturational age b. Gestational age c. Neurological age d. Chronological age

b. Gestational age

The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these symptoms indicate what? a. Respiratory distress syndrome b. Hypoglycemia c. Necrotizing enterocolitis d. Renal failure

b. Hypoglycemia

An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function? a. Immediately b. Within 3 days c. 1 to 2 weeks d. At least 1 month

b. Within 3 days

How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding? a. Check tube placement by injecting air into the stomach. b. Weigh the infant before the feeding. c. Aspirate stomach contents. d. Check serum glucose level

c. Aspirate stomach contents.

A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heart failure

c. Brain damage

When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age d. Late preterm

c. Large for gestational age

What is the rationale for placing a preterm infant born at 34 weeks of gestation in an incubator? a. The infant has a small body surface-to-weight ratio. b. Heat increases the flow of oxygen to the extremities. c. The infant's temperature control mechanism is immature. d. Heat within the incubator facilitates drainage of mucus.

c. The infant's temperature control mechanism is immature.

Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching about stimulating the infant tell the parents? a. To bring in colorful pictures and toys to place in the incubator b. That stimulating the infant during feedings increases intake c. To stroke the infant during feeding to increase intake d. Not to disturb the infant between feedings

c. To stroke the infant during feeding to increase intake

The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. What is the most appropriate nursing response? a. "Preterm infants usually remain smaller than term infants throughout childhood." b. "Your daughter will be the same size as other children by the time she is 1 year old." c. "Prematurity is associated with short stature but does not affect weight gain." d. "It takes about two years for the preterm infant to catch up to a full-term infant."

d. "It takes about two years for the preterm infant to catch up to a full-term infant."

The nurse is assessing a preterm infant. To what does the infant's level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infant's weight as compared to the gestational aged. d. Ability of the organs to function outside of the uterus

d. Ability of the organs to function outside of the uterus

The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity? a. Prostaglandins b. Oxytocin c. Magnesium sulfate d. Corticosteroids

d. Corticosteroids

Why is the postterm neonate at risk for cold stress? a. Inadequate vernix caseosa b. Hypoxia from a deteriorated placenta c. Polycythemia d. Fat stores have been used in utero for nourishment

d. Fat stores have been used in utero for nourishment

What symptoms of cold stress might the nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 40 mg/dL c. Warm skin with low core temperature d. Increased respiratory rate and periods of apnea

d. Increased respiratory rate and periods of apnea

The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant toexhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin

d. Loose, transparent skin

What deficiency causes a preterm infant respiratory distress syndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant

d. Surfactant