NURS 355 Chapter 9

Parents of an infant born at 36 weeks' gestation ask the nurse, "Will our infant need a car seat trial before being discharged?" What is the nurse's best response?

"Yes, to monitor for possible apnea and bradycardia while in the seat." It is recommended that infants younger than 37 weeks of gestation have a period of observation in an appropriate car seat to monitor for possible apnea and bradycardia. The trial is not done to check the size of the car seat or to determine if blanket rolls will be needed. The infant was born at 36 weeks of gestation, so it is recommended to perform a car sear trial.

What are possible premature infant complications from oxygen therapy and mechanical ventilation?

Bronchopulmonary dysplasia and retinopathy of prematurity Oxygen therapy, although lifesaving, is not without hazards. The positive pressure created by mechanical ventilation creates an increase in the number of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Oxygen therapy puts the infant at risk for retinopathy of prematurity. Anemia, necrotizing enterocolitis, cerebral palsy, persistent patent ductus, congestive heart failure, and cerebral edema are not primarily caused by oxygen therapy and mechanical ventilation.

What is an essential component in caring for the very low- or extremely low-birth-weight infant?

Coordinating care to reduce environmental stress One of the principles of care for high-risk neonates is close observation and assessment with minimum handling. The nurse checks the apical rate against the monitor readings on a regular basis. The infant's care is then clustered, and the infant is disturbed as little as possible. Holding an infant to help develop trust is not part of the assessment. In some areas, parents use "skin-to-skin" care with their infants. Although electronic monitoring devices are used, the nurse must validate the readings with the infant's data. For an ill neonate, excessive stimulation creates stress.

A newborn is diagnosed with retinopathy of prematurity. What should the nurse know about this condition?

Cryotherapy and laser therapy are effective treatments Cryotherapy and laser photocoagulation therapy can be used to minimize the vascular proliferation process that causes the retinal damage. Blindness can be prevented with early recognition and treatment. Long-term administration of oxygen is one of the causes. Oxygen should be used judiciously.

The nurse is providing care to a preterm infant. Which characteristic of daily care should be considered supportive?

Directed toward development of sleep organization Developmentally supportive care uses both behavioral and physiologic information as the basis of caregiving. A focus in preterm infants is to be alert for infant behavioral states and intervene during alert times. The parents should be taught how to recognize the infant's behavioral states. Infants sleep for approximately 1 1/2 hours. The parents can provide care when the infant is awake. Care should not be delivered on a fixed schedule. It should always be responsive to the infant's cues. The heart rate is at its lowest when the infant is in a sleep period. The infant should not be disturbed during this time if possible.

The home care nurse is visiting a 6-month-old infant with bronchopulmonary dysplasia (BPD). The nurse assesses the child for which signs of overhydration? (Select all that apply.)

Edema Weight gain of 1 lb in 1 week Nurses must be alert to signs of overhydration in an infant with BPD such as changes in weight, electrolytes, output measurements, and urine specific gravity and signs of edema. Six-month-old infants gain around 4 to 5 oz a week. One pound in 1 week would indicate fluid retention. Serum sodium of 140 mEq/L and urine specific gravity of 1.008 are normal values and indicate adequate fluid balance.

A preterm neonate has begun breastfeeding, but the infant tires easily and has weak sucking and swallowing reflexes. What is the most appropriate nursing intervention?

Feed the remainder of breast milk by the orogastric route If a preterm infant tires easily or has weak sucking when breastfeeding is initiated, the nurse should feed the additional breast milk by the enteral route. The nurse supports the mother in the attempts to breastfeed and ensures that the infant is receiving adequate nutrition. Breast milk should be used as long as the mother can supply it.

The parents of an infant who has just died decide they want to hold the infant after their infant has gone to the morgue. What is the most appropriate nursing intervention at this time?

Have the infant brought back to the unit, wrapped in a blanket, and rewarmed in a radiant warmer. The parents should be allowed to hold their infant in the hospital setting. The infant's body should be retrieved and rewarmed in a radiant warmer. The nurse should provide a private place where the parents can hold their child for a final time. If possible, to facilitate the parents' grieving, the nurse should bring the infant back to the unit. A photograph is an excellent idea, but it does not replace the parents' need to hold the child.

What should the nurse anticipate in an infant who was exposed to cocaine during pregnancy?

Hypertonia and jitteriness The nurse should anticipate neurobehavioral depression or excitability and implement care directed at the infant's manifestations. Few or no neurologic sequelae appear in infants born to mothers who used cocaine during pregnancy. The infant is usually a poor feeder, so hypoglycemia should be more likely than hyperglycemia. The infant usually has intrauterine growth restriction.

The nurse has been caring for an infant who has just died. The parents are present but appear to be "afraid" to hold the dead infant. What is the most appropriate nursing intervention?

Keep the infant's body available for a few hours in case they change their minds. When the parents are hesitant about holding and touching their infant, the nurse should wrap the infant in blankets and keep the infant's body on the unit for a few hours. Many parents change their minds after the initial shock of the infant's death. This will provide the parents time to see and hold their infant if they desire. Telling the parents there is nothing to fear minimizes the parents' feelings. The nurse should allow the family to parent their child as they wish in death, as in life.

What is a priority of care for an infant with an intraventricular hemorrhage?

Minimize interventions that cause crying The priority goal is to decrease intracranial pressure (ICP). Allowing the infant to cry will cause an increase in pressure. Analgesia is used as necessary to maintain the child pain free. This reduces ICP. The infant should be positioned with the body and head in the midline position. Turning the child's head to the right side can cause cerebral venous congestion and increased ICP. The child should have minimum stimulation to avoid increases in ICP.

A preterm infant who is being fed commercial formula by gavage has had an increase in gastric residuals, abdominal distention, and apneic episodes. Which is the most appropriate nursing action?

Notify the practitioner These are signs that may indicate early necrotizing enterocolitis. The practitioner is notified for further evaluation. Enteral feedings are usually stopped until the cause of increased residuals is identified.

What does the nursing care for infants with fetal alcohol syndrome (FAS) include?

Nutritional guidance Infants with FAS have characteristic poor feeding behaviors that persist throughout childhood. The nurse assists in devising strategies to improve nutrition. The infant is protected from overstimulation. FAS does not include cardiovascular problems. The effects of FAS do not depend on the quantity of maternal alcohol consumption.

Which is a characteristic of postmature infants?

Parchment-like skin In postterm infants, the skin is often cracked, parchment-like, and desquamating. Lanugo is usually absent. Scalp hair is usually abundant. Subcutaneous fat is usually depleted, giving the child a thin, elongated appearance.

The nurse is caring for a newborn who was born at 35 weeks of gestation and is considered a late preterm infant. What intervention should be included in the infant's care plan?

Promote skin-to-skin care in the immediate postpartum period Late preterm infants can usually tolerate skin-to-skin care in the immediate postpartum period, which enhances the bonding process with the parents. A late preterm infant should be given an early feeding of human milk or formula; dextrose water is not required for the first feeding. The hepatitis B vaccine and all newborn screening, including the hearing test, should be done before discharge, with no limitation on corrected age.

The nurse is preparing to administer a gavage feeding to an infant. The nurse should place the infant in which position for the feeding?

Prone with the head slightly elevated The gavage feeding is best performed when an infant is in a prone or a right side-lying position with the head slightly elevated. Supine and left side-lying with the head flat would not be a recommended position. The infant should not be gavage fed sitting in a car seat.

The nurse is teaching parents of a bottle-fed preterm infant techniques to facilitate feeding. Which techniques should the nurse include? (Select all that apply.)

Recognize the infant's limits Prepare a calm, quiet area for the feeding Ensure a restful environment between feedings Feeding facilitation techniques for preterm infants include recognizing the infant's limits; preparing a calm, quiet area for the feeding; and ensuring a restful environment between feedings. Using a firm nipple with slower flow and gently arousing the infant for the feeding are other facilitation techniques. Using a soft nipple and avoiding arousing the infant are techniques that would not facilitate feeding.

The nurse knows that during deep sleep the neonate should not be disturbed if possible. Characteristics of deep sleep include what?

Regular breathing Regular breathing is characteristic of deep sleep. During active sleep, irregular breathing may be present. Occasional smiling, rapid eye movements, and apneic pauses of less than 20 seconds are characteristic of active sleep.

Which refers to an infant whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

Small for gestational age A small-for-gestational-age, or small-for-date, infant is one whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. A postterm, or postmature, infant is any child born after 42 weeks of gestation, regardless of birth weight. A low-birth-weight infant is a child whose birth weight is less than 2500 g, regardless of gestational age.

he nurse is caring for a 3-week-old boy born at 29 weeks of gestation. While taking vital signs and changing his diaper after stooling, the nurse observes his color is pink but slightly mottled, his arms and legs are limp and extended, he has the hiccups, his respirations are deep and rapid, and his heart rate is regular and rapid. The nurse should recognize these behaviors as signs of what?

Stress These are signs of stress or fatigue in a newborn. Neonatal seizures usually have some type of repetitive movement, from twitching to rhythmic jerking movements. The behavior of a preterm infant may be inactive and listless. Respiratory distress is exhibited by retractions and nasal flaring.

What is a characteristic of most neonatal seizures?

Subtle and barely discernible Seizures in newborns may be subtle and barely discernible or grossly apparent. Most neonatal seizures are subcortical and do not have the etiologic or prognostic significance of seizures in older children. Clonic seizures are slow, rhythmic jerking movements. Generalized seizures are bilateral jerks of the upper and lower limbs that are associated with electroencephalographic discharges. Neonatal seizures are not well organized.

What is most descriptive of the signs observed in neonatal sepsis?

Subtle, vague, and nonspecific physical signs The signs of neonatal sepsis are usually characterized by the infant generally "not doing well." Poor temperature control, usually with hypothermia, lethargy, poor feeding, pallor, cyanosis or mottling, and jaundice, may be evident. Seizures are not a manifestation of sepsis. Severe neurologic sequelae may occur in low-birth-weight infants with sepsis. Hyperthermia is rare in neonatal sepsis. Urinary output is not affected by sepsis.

In about 1 week, a stable preterm infant will be discharged. The nurse should teach the parents to place the infant in which position for sleep?

Supine The American Academy of Pediatrics recommends that healthy infants be placed to sleep in a nonprone position. The prone position is associated with sudden infant death syndrome but can be used for supervised play.

An infant of a mother with herpes simplex infection has just been born. What should nursing considerations include?

The mother and infant should be together in a private room The herpes virus can be transmitted to the infant intrapartum or by direct contact. The mother and infant should room together in a private room to reduce the risk of transmission to other infants and mothers. The infant should be kept with the mother. Placement in the nursery creates the possibility of transmission of the virus. Immediate discharge is not necessary. Good handwashing and a private room will minimize the risk of transmission while allowing the mother and infant to receive postpartum care.

The nurse is planning care for a family expecting their newborn infant to die because of an incurable birth defect. What should the nurse's interventions be based on?

The parents should be given the opportunity to "parent" the infant, including seeing, holding, touching, or talking to the infant in private. Providing care for the neonate is an important step in the grieving process. It gives the parents a tangible person for whom to grieve, which is a key component of the grieving process. Tangible remembrances and photographs can make the infant seem more real to the parents. Many neonatal intensive care units make bereavement memory packets, which may include a lock of hair, handprints, footprints, a bedside name card, and other individualized objects. Families need to be informed of their options. The ritual of a funeral provides an opportunity for the parents to be supported by relatives and friends.

Which statement is true concerning the nutritional needs of preterm infants?

The secretion of lactase is low. The enzyme lactase is not readily available in an infant's body until after 34 weeks of gestation. Formulas containing lactose are not well tolerated. Carbohydrates and fats are less well tolerated than protein. Preterm infants require significantly higher intake of calories and other nutrients than full-term infants. The American Academy of Pediatrics recommends 105 to 130 kcal/kg/day. Breast milk from the infant's mother is considered the ideal enteral nutrition for the infant. Several commercial formulas are designed for preterm infants.

A preterm infant with respiratory distress syndrome is receiving inhaled nitric oxide (NO). What is the reason for administering the inhaled nitric oxide?

To reduce pulmonary vasoconstriction and pulmonary hypertension NO is used for infants with conditions such as meconium aspiration syndrome, pneumonia, sepsis, and congenital diaphragmatic hernia. Most infants with these disorders do have mature lungs. NO is not oxygen. Inhaled NO is beneficial for infants with meconium aspiration syndrome, but it does not work by removing debris. Inhaled NO is a significant treatment for infants with persistent pulmonary hypertension, pulmonary vasoconstriction, and subsequent acidosis and severe hypoxia. When inhaled into the lungs, it causes smooth muscle relaxation and reduction of pulmonary vasoconstriction and subsequent pulmonary hypertension.

The nurse is admitting a drug-exposed newborn to the neonatal intensive care unit. The nurse should assess the newborn for which signs of withdrawal? (Select all that apply.)

Tremors Nasal stuffiness Loose, watery stools Signs of withdrawal in a drug-exposed newborn include increased tone; increased respiratory rate; disturbed sleep; fever; excessive sucking; and loose, watery stools. Other signs observed included projectile vomiting, mottling, crying, nasal stuffiness, hyperactive Moro reflex, and tremors.

The neonatal intensive care nurse is planning care for an infant in an incubator. Which interventions should the nurse plan to assure therapeutic visual stimulation for the neonate?

Use an incubator cover Decrease ambient light levels by using an incubator cover and by dimming lights, not keeping them bright. Avoid placing a cloth over the face because it will cause tactile irritation. Avoid leaving visual stimuli in the beds of infants who cannot escape from it.

The nurse is caring for a preterm infant who is receiving caffeine citrate for treatment of apnea of prematurity. What signs should indicate caffeine toxicity?

Vomiting and irritability Caffeine citrate is the medication of choice for the treatment of apnea of prematurity because it has fewer side effects, requires once-daily dosing, has slower elimination, and has a wider therapeutic range than other options. Caffeine toxicity can still occur, so the preterm infant needs to be monitored for signs of toxicity, including vomiting and irritability. Bradycardia, hypotension, oliguria, sleepiness, constipation, and weight loss are not symptoms of toxicity.

The nurse is monitoring an infant's temperature to avoid cold stress. The nurse understands that cold stress in the infant can cause which complications? (Select all that apply.)

hypoxia hypoglycemia metabolic acidosis Cold stress poses hazards to the neonate through hypoxia, metabolic acidosis, and hypoglycemia. Cold stress does not cause respiratory alkalosis. The infant lacks a shivering response, so it is not a complication of cold stress.

A woman in premature labor delivers an extremely low-birth-weight (ELBW) infant. Transport to a neonatal intensive care unit is indicated. The nurse explains that which level of service is needed?

level IIIB A level IIIB neonatal unit has the capability of providing care for ELBW infants, including high-frequency ventilation and on-site access to medical subspecialties and pediatric surgery. A level I facility manages normal maternal and newborn care. Infants at less than 35 weeks of gestation are stabilized and transported to a facility that can provide appropriate care. A level IA facility does not exist. Level II facilities provide care for infants born at 32 weeks of gestation and weighing more than 1500 g. If the infant is ill, the health problems are expected to resolve rapidly and are not anticipated to require specialty care.

The neonatal intensive care nurse is caring for a neonate born at 36 weeks of gestation in an incubator. Which actions should the nurse plan to assure adequate skin care for the neonate? (Select all that apply.)

removing adhesives or skin barriers slowly applying emollient as needed for dry, flaking skin using cleanser or soaps no more than 2 or 3 times a week Skin care for the neonate involves removing adhesive or skin barriers slowly, supporting the skin underneath with one hand and gently peeling away from the skin with the other hand. Emollient should be applied as needed for dry, flaking skin, and cleansers or soaps should be used no more than two or three times a week because they can dry the skin. Adhesive remover, solvents, and bonding agents should be avoided. Adhesives should not be removed for at least 24 hours after application, not 12.

The health care provider has prescribed surfactant, beractant (Survanta), to be administered to an infant with respiratory distress syndrome (RDS). The nurse understands that the beractant will be administered by which route?

via the ET tube Surfactant is administered via the ET tube directly into the infant's trachea.

A mother planned to breastfeed her infant before giving birth at 33 weeks of gestation. The infant is stable and receiving oxygen. What is the most appropriate nursing action related to this?

Assess the infant's readiness to breastfeed. Research confirms that human milk is the best source of nutrition for term and preterm infants. Preterm infants should be breastfed as soon as they have adequate sucking and swallowing reflexes and no other complications such as respiratory complications or concurrent illnesses. If the infant has adequate sucking and swallowing, the infant should breastfeed for some of the feedings. The mother can express milk to be used in her absence.

What is the most common cause of iatrogenic anemia in preterm infants?

Frequent blood sampling The most common cause of anemia in preterm infants is frequent blood-sample withdrawal and inadequate erythropoiesis in acutely ill infants. Microsamples should be used for blood tests, and the amount of blood drawn should be monitored. Respiratory distress syndrome, meconium aspiration syndrome, and persistent pulmonary hypertension are not causes of anemia. They may require frequent blood sampling, which contributes to the problem of decreased erythropoiesis and anemia.

A preterm infant of 33 weeks of gestation is admitted to the neonatal intensive care unit. Approximately 2 hours after birth, the neonate begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. What should the nurse recognize?

Further evaluation is needed. These are signs of respiratory distress syndrome and require further evaluation. There is no way to predict the infant's clinical course based on the available data. Cyanosis may be present, but these are significant findings indicative of respiratory distress even without cyanosis.

What explains why a neutral thermal environment is essential for a high-risk neonate?

It permits the neonate to maintain a normal core temperature with minimum oxygen consumption. A high-risk neonate is at greater risk for cold stress than a term infant because of the smaller muscle mass and fewer deposits of brown fat for producing heat, lack of insulating subcutaneous fat, and poor reflex control of skin capillaries. By definition, a neutral thermal environment is one that permits the infant to maintain a normal core temperature with minimum oxygen consumption and caloric expenditure. Smaller muscle mass and poor reflex control of skin capillaries decrease the ability of a high-risk neonate to compensate for an environment that is not thermoneutral. Metabolism increases in an infant experiencing cold stress, creating a compensatory increase in oxygen and caloric consumption. Increased caloric consumption is to be avoided. Neonates need available calories for growth.

The nurse is caring for a neonate with an intraventricular hemorrhage. What interventions should the nurse avoid to prevent any increase in intracranial pressure? (Select all that apply.)

Keeping the head of the bed flat Suctioning the endotracheal tube frequently Some nursing procedures increase intracranial pressure (ICP). For example, blood pressure increases significantly during endotracheal suctioning in preterm infants, and head positioning produces measurable changes in ICP. ICP is highest when infants are in the dependent (flat) position and decreases when the head is in a midline position and elevated 30 degrees. Keeping the environment quiet, handling the neonate minimally, and maintaining the neonate's head in a midline position are measures to keep the ICP down.

The nurse is positioning a preterm neonate. What are therapeutic positions the nurse should implement? (Select all that apply.)

Neutral or slightly flexed neck Trunk slightly rounded with pelvic tilt Hips partially flexed and adducted to near midline Therapeutic positioning of the neonate includes a neutral or slightly flexed neck and the trunk slightly rounded with the pelvis tilted and hips partially flexed and adducted to near midline. The elbows should be flexed, not extended, and the hands should be brought to the face or midline as the position allows, not by the side.

A preterm infant is being fed by gavage. What is an important consideration for this infant?

Provide a pacifier for nonnutritive sucking during bolus feeding. Nonnutritive sucking during feedings will help the infant associate sucking with food. This can minimize feeding resistance and aversion. Warming the feeding to body temperature is not necessary. The food can be at room temperature. If possible, the infant should be held in a feeding position. The infant should be allowed to become hungry so that the food and nonnutritive sucking are associated with satisfying the hunger.

While a mother is feeding her high-risk neonate, the nurse observes the neonate having occasional apnea, pallor, and bradycardia. What is the most appropriate nursing action?

Recognize that this may indicate an underlying illness Apnea, pallor, and bradycardia may be signs of an underlying illness. The infant should be evaluated to ensure he or she is not developing problems. The infant can rest while waiting for the evaluation. If the child is becoming ill, the capacity to digest enteral feedings may be compromised. The type of nipple that is being used should not produce the signs being observed.

Which is an important nursing action related to the use of tape or adhesives on premature neonates?

Remove adhesives with water, mineral oil, or petrolatum Warm water, mineral oil, or petrolatum can facilitate the removal of adhesive. In a premature neonate, often it is impossible to avoid using adhesives and tape. The smallest amount of adhesive necessary should be used. Scissors should not be used to remove dressings or tape from very small and immature infants because it is easy to snip off tiny extremities or nick loosely attached skin. Solvents should be avoided because they tend to dry and burn the delicate skin.

The nurse is caring for a high-risk neonate who has an umbilical catheter and is in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?

Report the findings immediately to the practitioner. Blanching of the feet in a neonate with an umbilical catheter is an indication of vasospasm. Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair circulation. It is an emergency situation and must be reported immediately.

Which statement best describes the characteristics of preterm infants?

Sucking reflex is absent weak, or ineffectual Reflex activity is only partially developed. Sucking is absent, weak, or ineffectual. Thermoregulation is poorly developed, and a preterm infant needs to be in a neutral thermal environment. A preterm infant may be listless and inactive compared with the overall attitude of flexion and activity of a full-term infant. A preterm infant's head is proportionately larger than the body.

The nurse is caring for a neonate with respiratory distress syndrome. The infant has an endotracheal tube. What should nursing considerations related to suctioning include?

Suctioning should not be carried out routinely Suctioning is not an innocuous procedure and can cause bronchospasm, bradycardia, hypoxia, and increased intracranial pressure (ICP). It should never be carried out routinely. The Trendelenburg position should be avoided because it can contribute to increased ICP and reduced lung capacity from gravity pushing the organs against the diaphragm.

The nurse is attending a delivery of a full-term infant with meconium noted in the amniotic fluid. The nurse should understand that what action should be performed in the delivery room?

The infant's mouth, nose, and posterior pharynx will be suctioned just after the head is delivered while the chest is still compressed in the birth canal. Meconium aspiration syndrome can occur when a fetus is subjected to intrauterine stress that causes relaxation of the anal sphincter and passage of meconium into the amniotic fluid, and the meconium-stained fluid is aspirated with the first breath. To prevent meconium aspiration, the infant's mouth, nose, and posterior pharynx should be suctioned just after delivery of the head while the chest is still compressed in the birth canal. A DeLee trap is no longer used in the delivery room. The infant's mouth should be suctioned before the nose and during the delivery, not at the completion of delivery. The infant should not take its first breath without suctioning first and may or may not require tracheal suctioning.

When caring for a neonate in a radiant warmer, what should the nurse be alert to?

Transepidermal water loss leading to dehydration Radiant warmers result in greater evaporative fluid loss than normal, thus predisposing the infant to dehydration. Plastic wrap can help reduce this loss. Daily fluid requirements are increased to compensate. The radiant warmer protects the infant from cold stress. Plexiglas shields are not used in radiant warmers because they block the radiant heat waves. With clean and aseptic technique, there is not a greater risk of infection.

Women who smoke during pregnancy are most likely to have infants who are what?

growth restricted in weight, length, and chest and head circumference Infants born to mothers who smoke have retardation in all aspects of growth. Infants of mothers with diabetes are large for gestational age. Infants of mothers who smoke are small for gestational age.

What can stroking infants who are physiologically unstable result in?

Decreased oxygen saturation Tactile interventions can have both positive and negative effects on neonates. For physiologically unstable infants and those who are disturbed during sleep, outcomes such as gasping, grunting, decreased oxygen saturation, apnea, and bradycardia have been observed. Fewer sleep periods are not associated with tactile stimulation in physiologically unstable infants. Increased weight gain and shortened hospital stays are positive outcomes that are observed when tactile stimulation is done at developmentally supportive times.

Which is a central factor responsible for respiratory distress syndrome in a newborn?

Deficient surfactant production The successful adaptation to extrauterine breathing requires numerous factors, which most term infants successfully accomplish. Preterm infants with respiratory distress are not able to adjust. The most likely central cause is the abnormal development of the surfactant system. The number and state of development of the alveoli are not central factors in respiratory distress syndrome. The instability of the alveoli related to the lack of surfactant is the causative issue. The bronchioles are sufficiently developed in newborns.

The nurse is caring for an infant born at 37 weeks of gestation of a nondiabetic mother just admitted to the neonatal intensive care unit for observation. The nurse notes that which lecithin/sphingomyelin (L/S) ratio obtained before delivery indicates no risk of respiratory distress syndrome (RDS)?

2:1 An L/S ratio of 2:1 in nondiabetic mothers indicates virtually no risk of RDS.

The nurse is placing an infant in a servocontrol radiant warmer. The nurse should attach the temperature probe to which area of the infant's body?

Abdomen The temperature probe should be placed over a nonbony, well-perfused tissue area such as the abdomen or flank. The scapula, sternum, and front of the lower leg would be a bony area.

What signs should the nurse expect when a pneumothorax occurs in an infant on mechanical ventilation?

Abrupt duskiness or cyanosis The early signs of a pneumothorax in an infant on mechanical ventilations include the abrupt onset of duskiness or cyanosis. Tachypnea is the presenting sign. Usually the heart rate is decreased. The heart sounds usually become muffled, diminished, or shifted. The pulse pressure decreases in pneumothorax.

The nurse is caring for a neonate on positive-pressure ventilation. The nurse monitors for which complications of positive-pressure ventilation? (Select all that apply.)

Pneumothorax Pneumomediastinum Pulmonary interstitial emphysema Positive-pressure introduced by mechanical apparatus increases complications such as pulmonary interstitial emphysema, pneumothorax, and pneumomediastinum. Respiratory distress syndrome and meconium aspiration syndrome are not complications of positive-pressure ventilation.

The nurse is caring for a preterm neonate who requires mechanical ventilation for treatment of respiratory distress syndrome. Because of the mechanical ventilation, the nurse should recognize an increased risk of what?

Pneumothorax Positive pressure introduced by mechanical apparatus has created an increase in the incidence of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Tachypnea may be an indication of a pneumothorax, but it should not be transient. Meconium aspiration is not associated with mechanical ventilation. Retractions and nasal flaring are indications of the use of accessory muscles when the infant cannot obtain sufficient oxygen. The use of mechanical ventilation bypasses the infant's need to use these muscles.