Maternity Chap 13
. 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
The mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the nurses 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 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
The nurse is caring for an infant born at 43 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
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 infants eyes covered at all times.
a
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
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
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
a, b, c
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. Polycythemia
a, b, e
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
a, d, e
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
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
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 infants feet or back. c. Ventilate with an Ambu bag. d. Perform nasopharyngeal suctioning.
b
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
The nurse in a pediatricians 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. 1 b. 2 c. 3 d. 4
b
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
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
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
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
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
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 infants temperature control mechanism is immature. d. Heat within the incubator facilitates drainage of mucus.
c
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
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
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
The nurse is assessing a preterm infant. To what does the infants level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infants weight as compared to the gestational age d. Ability of the organs to function outside of the uterus
d
The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin
d
What deficiency causes a preterm infant respiratory distress syndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant
d
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
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