RNC-NIC Questions Ch 8-10 General Assessment and Management
During a physical examination an infant's point of maximal impact is noted to be to the right of the mediastinum. The nurse should anticipate which of the following conditions? A. Left-sided pneumothorax B. Levocardia C. Right-sided pleural effusion D. Left-sided atelectasis
A. A tension pneumothorax on the left will shift the mediastinum to the right, moving the point of maximal impulse (PMI) to the right. Levocardia is the normal position of the heart, which places the PMI to the left of the sternum. A pleural effusion on the right would push the mediastinal structures to the left, pushing the PMI to the left; this would position the PMI further to the left.
Maturational hypotonia can lead to acquired positioning malformations in preterm infants, which include abnormal head molding, hip adduction, external rotation, and: A. arching posture. B. fixed neck flexion. C. wrist and ankle torsion. D. scapular abduction and shoulder extension.
A. Abnormal head molding, hip adduction and external rotation, and arching posture are prevented by correct neurodevelopmental positioning. Fixed neck extension is an acquired positioning malformation that can be prevented by appropriate positioning. Wrist and ankle torsion are not acquired positioning malformations. Scapular adduction and shoulder retraction are acquired positioning malformations that can be prevented by appropriate positioning.
Feeding success has implications for mother-infant bonding, as well as decreasing length of NICU stay. Interventions that facilitate feeding success include: A. paced feeding, kangaroo care before feedings and provision of non-nutritive sucking. B. continuous drip feedings, appropriate type of nipple, and increasing environmental stimuli at feeding time. C. appropriate temperature of feedings, vigorous patting to encourage adequate burping, and use of high-flow nipple. D. clustering of care, playing of music in the incubator 6-12 hours a day, and use of a rocking mattress.
A. Feeding success can be facilitated by decreasing environmental stimuli to allow the infant to focus on the feeding and avoid overstimulating and overwhelming the infant; reducing the stress of burping by positioning and gentle handling; using paced feedings to allow for reorganization of suck, swallowing, and breath coordination; providing kangaroo care before feedings; and providing nonnutritive sucking. Nipple type needs to be continuously evaluated and individualized. There is no consensus on the warming of feedings, but extremes in temperature should be avoided. Use of a high-flow nipple can lead to coughing and choking. Hours of music playing increases ambient noise levels; rocking mattresses may be overstimulating.
The potential adverse effect(s) of lipid emulsions for the preterm infant is (are): A. impaired pulmonary gas exchange and bilirubin toxicity. B. hypolipidemia. C. hypernatremia and hyperkalemia. D. hypoglycemia.
A. High lipid infusion rates can be associated with decreases in oxygenation and the displacement of bilirubin from albumin-binding sites. Additional adverse effects include increased pulmonary vascular resistance, sepsis, and oxygen free-radical stress. Premature infants less than 28 weeks' gestation are vulnerable to hyperlipidemia via lipid emulsion infusions due to reduced lipoprotein lipase activity and triglyceride clearance. Lipid emulsions should not directly lead to hypernatremia and hyperkalemia. Lipid emulsions can cause hyperglycemia, especially with rates greater than 6 g/kg/day.
Which chest x-ray findings best represent primary surfactant deficiency? A. Hypoexpansion, air bronchograms, reticulogranular pattern. B. Hyperexpansion, fluid in the fissure, air bronchospasms C. Bilateral streakiness, hyperexpansion, reticulogranular pattern D. Hypoexpansion, sail sign, fluid in the fissure
A. Hypoexpansion due to atelectasis, air bronchospasms from atelectasis of the alveoli interspersed with open airways and a reticulogranular pattern, and open alveoli interspersed with atelectatic alveoli are the classic findings of surfactant deficiency. Hyperexpansion does not occur with surfactant deficiency. Fluid in the fissures is common in transient tachypnea of the newborn because there is a delay in the clearance of lung fluid after birth. Bilateral streakiness is found with pneumonia related to the infectious processes. The sail sign is a common finding with pneumomediastinum and reflects elevation of the thymus gland from the free air.
Effects and benefits of kangaroo care have been reported with as little as 10 minutes of kangaroo care. Which statement best describes the research findings on kangaroo care? A. Kangaroo care has positive effects on breast-feeding, sleep, and infection rates. B. Kangaroo care interval is best described as one sleep cycle - approximately 2 hours. C. Kangaroo care increases anxiety in parents due to worry about monitoring of their baby. D. Kangaroo care is embraced uniformly by all staff members, and there are no barriers to its use.
A. Kangaroo care has been reported to enhance parental bonding and increase confidence. Other beneficial effects are improved breast-feeding, improved sleep patterns, and lower infection rates. One does is best described as one sleep-wake cycle, which is 65 minutes in preterm infants. Barriers remain to full implementation due to issues of infant and parent readiness, as well as staff time.
The nurse explains to the parents of a premature infant that maternal breast milk is the optimal primary nutritional source due to which of the following? A. Reduces the risk of necrotizing enterocolitis B. Meets nutritional requirements of premature infants C. Increases rate of growth compared with formula-fed infants D. Does not contain bacteria or viruses that could cause illness
A. Maternal breast milk is the optimal primary nutritional source for premature neonates because evidence has shown that it reduces the incidence of necrotizing enterocolitis. Maternal breast milk does not completely meet all the nutritional needs of premature infants. Therefore premature infants fed human milk may have slower growth rates compared with infants fed formula. Maternal breast milk does contain bacteria and viruses.
Repetitive noxious stimuli to the mouth, such as suctioning, can result in which developmental disorder? A. Oral aversion B. Feeding strike C. Feeding opposition D. Feeding intolerance
A. Oral aversion can develop in response to repetitive invasive procedures, feeding on a schedule instead of on demand, and having multiple caregivers. Feeding strike occurs when a baby refuses to breast-feed and is not in the process of being weaned. Feeding opposition is a nonexistent term. Signs of feeding intolerance are abdominal distention, emesis, residuals, and blood in the stool.
A nurse is teaching a mother to feed her preterm baby by keeping the nipple in the infant's mouth and regularly tilting the bottle slightly to stop the flow of the expressed mother's milk. This method of shortened sucking bursts that lets the infant pause, swallow, and breath is referred to as: A. paced feeding. B. synactive feeding C. infant-driven feeding. D. interactive feeding.
A. Paced feeding supports feeding success by coordinating sucking, promoting swallowing, regulating breathing breaks, and increasing stability. The synactive model of infant behavior is a major theoretic framework for establishing physiologic stability as the foundation for the organization of motor state and attentive-interactive behaviors. In infant-driven feeding, the baby determines when to be fed. Interactive feeding is a nonexistent term.
A mother is caring for her infant daughter who is now 31 weeks adjusted age. The mother tells the nurse that she was reading about sleeping in preterm infants and would like to understand more about transitional sleep in preterms. The nurse would explain that transitional sleep: A. is the predominate sleep state for infants under 36 weeks' gestation. B. helps a preterm infant transition from rapid eye movement (REM) to non-REM sleep. C. is a more active form of quiet sleep. D. helps preterm infants learn to decrease their sleep time.
A. Preterm infants do not have significant quiet sleep cycles until approximately 36 weeks' gestation; hence a third sleep state called transitional sleep is identified in preterm infants. Transitional sleep is not a sleep stat between REM and non-REM, but rather an additional type of sleep state because preterms do not have organized REM and non-REM sleep states. Transitional sleep is characterized by quiet sleep with a period of closed eyes, regular or periodic breathing, no body movements, and no REM. Transitional sleep is not done to decrease sleep time, but rather used to describe the sleep stat while the preterm infant sleep states are maturing.
Signs of sensory overstimulation in neonates include finger and toe splaying, gaze aversion, and hiccups. The most appropriate nursing intervention to provide neurodevelopmental support to an infant exhibiting one or more of these behaviors during nursing care is to: A. swaddle the baby and provide a time-out for rest and recovery. B. dim the lights to decrease stimulation and continue with care. C. play music during care to provide auditory distraction and calm the infant. D. hurry and finish the care being provided to shorten the noxious exposure.
A. Swaddling the baby and implementing a time-out for rest and recovery provide neurodevelopmental support, promote self-regulatory behavior, and allow return to physiologic homeostasis. Just dimming the lights may not decrease stimulation enough to allow for recovery of physiologic stability. Playing music during care to provide auditory distraction is not recommended because the noise may add to the overstimulation and decompensation. If signs of stress are exhibited, care activities should be stopped and the baby allowed to recover physiologic stability. Continuing with care could lead to further disorganization and physiologic and behavioral stress.
Which of the following element(s) may not be needed in the total parenteral nutrition for the first several days of life due to diuresis and the establishment of renal function in the extremely low-birth-weight infant? A. Sodium and potassium B. Magnesium C. Amino acids D. Calcium
A. The addition of sodium and potassium to parenteral nutrition may not be needed for the first several days in extremely low-birth-weight infants because of the expected free water diuresis during the first week of life and their immature renal function. Fetal mineral stores of magnesium accumulate late in gestation. Magnesium is an essential mineral, and parenteral supplementation should commence on the first day of life for stabilization of serum calcium values and bone mineralization and growth. Parenteral amino acid supplementation should begin immediately after the birth to promote growth. Fetal mineral stores of calcium accumulate late in gestation. Calcium is an essential mineral, and adequate supply of parenteral calcium immediately after birth is crucial to reduce the risk of early hypocalcemia.
A very-low-birth-weight infant has received several weeks of parenteral nutrition. Laboratory studies reveal a conjugated (direct) bilirubin level of 2 mg/dL. The infant should be evaluated for which of the following? A. Cholestatic jaundice B. Pneumatosis C. Glucose-6-phosphate dehydrogenase deficiency D. Intraventricular hemorrhage
A. The primary complication of prolonged parenteral nutrition is cholestatic jaundice because TPN has been recognized as an important cause of intracellular and intracanalicular cholestasis. Conjugated hyperbilirubinemia is never normal and should always be evaluated. Pneumatosis is a radiographic finding caused by gas within the bowel wall and is a pathologic sign of NEC and is not a primary complication of TPN. G6PD deficiency is an X-linked genetic condition that is associated with severe hemolytic jaundice and anemia after exposure to certain triggers. Intraventricular hemorrhage is a hemorrhage that occurs in the germinal matrix, ruptures into the lateral ventricle, and can lead to acute enlargement of the lateral ventricle.
An infant undergoes placement of an umbilical arterial catheter. The nurse should anticipate which of the following to reflect proper placement for a high-lying catheter per chest/abdominal x-ray? A. Thoracic vertebrae 3-5 B. Thoracic vertebrae 6-9 C. Lumbar vertebrae 1-3 D. Thoracic vertebrae 11-12
B. Accurate high umbilical arterial catheter placement is between the thoracic vertebrae 6 and 9. Low placement is between lumbar vertebrae 3 and 4. Placing the catheter at thoracic vertebrae 3 to 5 and 11 to 12 and lumbar vertebrae 1 to 3 will avoid areas of the celiac, mesenteric, and renal arteries.
Developmental care is in various stages of implementation in NICUs. An example of how an individual nurse may foster developmental care when doing direct care for an individual patient is: A. teaching the family the quickest way to complete a bath. B. alerting the infant to any care activity by speaking softly to him or her and making physical contact with him or her. C. allowing the infant to cry and learn self-consoling as he or she matures. D. educating the parents on the unit times for caregiving.
B. Alerting the infant to changes has two goals: one is to allow the infant to have a smoother state transition and the other allows the caretaker to observe for subtle signs of discomfort or engagement. Bathing should be a relaxing, soothing experience for the infant. He or she should be in a tucked position for an immersion bath, using a blanket, towel, or hoands to keep the infant calm and comfortable. Infants should be comforted as quickly as possible. This decreases the negative effects that physiologic changes may have and helps to establish trust versus mistrist with the caregivers. Longer periods of crying usually take longer to consol. Caregiving should be based on the infant and family schedule. This is often the major challenge NICUs have in coordinating the needs of the unit with the needs of the family.
A nurse is floating to the NICU and caring for infants in the feeder-grower area of the unit. After feeding, she swaddles the infant tightly with the arms down at the sides and places the infant in a Back to Sleep position. Her NICU "buddy" discusses with her the NICU Back to Sleep program and some other elements of developmental care. One item the NICU buddy highlights is: A. Back to Sleep is only for babies who are going home in 2 days. B. babies need to have access to their hands for self-consoling behaviors. C. after feeding, the babies are placed prone for 30 minutes and then put on their back. D. swaddling a Back to Sleep infant helps them feel more secure when learning to sleep on the back.
B. Back to Sleep "dressing" may include a sleep sac or blanket up to the nipple line. Infants should always have access to their hands for self-consoling behaviors. Back to Sleep protocols need to be initiated in the NICU, giving the infant enough time to adjust to the supine sleeping and to pattern the behavior for families. Infants may be excluded based on airway obstructions or birth defects, for example. Once Back to Sleep protocols are started, an infant is placed supine after feeds. The infant's needs are assessed and individualized. Infants who are "Back to Sleep" should not be completely swaddled. Appropriately identified NICU infants should be in a sleeper and/or wrapped only to the nipple level. Patterning behavior for the family with the Back to Sleep program would include minimizing the amount of blankets and bedding in the bed.
Which of the following parameters post-hospital discharge of a former 28-week-gestation infant should be considered a high priority for the nurse? A. Body mass index for age B. Weight, length, and head circumference C. Weight for stature D. Weight for age.
B. Careful assessment of sex-appropriate weight, length, and head circumference for age should be performed at discharge and regularly after discharge using appropriate growth curves. According to the CDC, body mass index, stature for age, and weight for stature are clinically indicated for children and adolescents 2-20 years old.
The purpose of adding carnitine to total parenteral nutrition solutions for preterm infants who are nothing-by-mouth and receiving intravenous lipids is to: A. facilitate digestion of lactose. B. transport long-chain fatty acids. C. synthesize bile acids. D. support gut integrity.
B. Carnitine is a carrier molecule needed to transport long-chain fatty acids into mitochondria for oxidation. Preterm infants less than 34 weeks' gestation are usually dependent on lipids as an energy source and are at risk of not being able to appropriately store and synthesize carnitine, therefore, requiring supplementation in total parenteral nutrition solutions. Lactase is the enzyme necessary for the digestion of lactose. Cholesterol is a major component of cell membranes and synthesizes bile acids. Glutamine is a key amino acid, which may play an important role in supporting gut integrity and acts as a substrate for small intestinal mucosa.
The proteins whey and casein exist in a ratio of 80 (whey) to 20 (casein) in which of the following? A. Mature breast milk B. Colostrum C. Cow milk-based formula D. Soy-based formula
B. Colostrum whey:casein ratio is 80:20. Mature breast milk whey:casein ration is 55:45. Cow milk-based formula whey:casein ratio is 60:40. Soy-based infant formula does not contain whey and casein proteins.
A parent begins tapping on the incubator to wake up a sleeping infant for a visit. The most appropriate intervention at this time is to: A. suggest that the parent wait until the infant is awake. B. identify a state-appropriate activity that the parent can do. C. encourage the parent's interactions with the infant. D. gently discourage the parent by stating, " The baby doesn't like that."
B. If at all possible, a sleeping infant should not be awakened. If it is necessary to awaken the infant, as gentle a method as possible should be used. Nurses should educate parents on their infant's behavioral states and cues. Parental involvement should never be discouraged, but if the interaction is inappropriate, parents should be given alternatives. Because infants spend so much time asleep, parents need to be taught activities that they can do even while their infant is asleep. A goal of developmentally supportive care is to minimize external auditory stimuli. Tapping on the incubator should be avoided.
Implementing an evidence-based standardized feeding guideline by the nurse should lead to an: A. increased incidence of necrotizing enterocolitis. B. improved rates of growth. C. higher rates of practice variation within a facility. D. increased the amount of time to reach full enteral feeds.
B. Implementing evidence-based standardized feeding guidelines can decrease rates of practice variation and lead to improved rates of growth velocity and improved clinical outcomes (ie, decreasing the duration of parenteral nutrition, decreasing the time to reach full enteral feeds, minimizing incidence of NEC)
Which of the following best describes neurodevelopmentally supportive positioning? A. Muscle tone and reflex development proceeds from upper to lower extremities. B. Intentional movement by newborns enhances neuromuscular development and stability. C. Pushing against boundaries should be avoided to prevent pressure on the developing joints. D. Any position that allows movement will increase physiologic stress and should be avoided.
B. Intentional movement by newborns enhances neuromuscular development and stability. Muscle tone and reflex development proceed in a caudocephalad direction, from lower to upper extremities. Nesting or containment should not restrict the movement necessary for growth and development, and providing boundaries can assist with motoric stability such as posture and movement. Regulatory efforts such as pushing against boundaries are an example of intentional movement. Restraint of movement should be limited to as short a period as necessary.
The predominant disaccharide in human milk is: A. sucrose. B. lactose. C. fructose. D. glucose.
B. Lactose is the main disaccharide in human milk and is hydrolyzed into glucose and galactose in the small intestine by the enzyme lactase. Sucrose is a disaccharide and is hydrolyzed into glucose and fructose in the small intestine. Fructose is a monosaccharide that is predominately found in plants. Glucose is a monosaccharide that is predominately found in food as a building block in complex carbohydrates.
Which of the following is a benefit of minimal enteral (trophic) feedings in the preterm infant? A. Sufficient calories to sustain somatic growth B. Promote intestinal maturation with small volumes C. Enhance villous atrophy D. Replace the need for parenteral nutrition
B. Minimal enteral or trophic feedings facilitate intestinal maturation with small volumes (typically less than 24 mL/kg/day). Minimal enteral or trophic feedings are hypocaloric and do not contain sufficient calories to sustain somatic growth. Minimal enteral or trophic feedings facilitate intestinal maturation, and the lack of any enteral feedings may lead to intestinal villous atrophy. Minimal enteral or trophic feedings are hypocaloric, low-volume feeds and do not replace the need for parenteral nutrition.
An appropriate nursing intervention to provide developmental support to an infant during gavage feeding is to : A. feed on a strictly routine schedule. B. provide non-nutritive sucking before, during, and after the procedure. C. use a bright light to allow visualization of the correct placement of the tube. D. restrain the infant's body in an extended, supine posture with a soft fabric restraint to prevent the tube from being dislodged.
B. Nonnutritive sucking accelerates maturation of the sucking reflex and improves weight gain. Consideration of what has been happening to the infant and readiness for care are always important. Feeding should be infant driven rather than on a routine schedule. Reduction of noxious stimuli increases physiologic stability, potentially improving blood flow to the gut. Prone or side-lying positioning improves gastric emptying and decreases regurgitation.
An infant has an x-ray taken after intubation. The nurse should anticipate which of the following to reflect proper placement of the endotracheal tube? A. One cm below the carina B. Midway between thoracic inlet and carina C. At level of clavicles D. The fifth thoracic vertebra
B. Proper placement of an endotracheal tube is midway between the thoracic inlet and the carina. Placement one centimeter below the carina or at the fifth thoracic vertebrae would result in a right mainstem bronchial placement. Placement at the level of the clavicles is too high and places the infant at risk for self-extubation.
The nurse should explain to the parents that their premature infant needs to gain approximately how may grams per day to achieve adequate growth? A. 5 B. 15 C. 80 D. 100
B. The infant needs to gain approximately 15 g/day for optimal weight gain. Infants who do not grow at intrauterine growth rates are vulnerable for energy and protein deficits in addition to postnatal growth restriction. Infants who grow in excess of intrauterine growth rates may be vulnerable to later risks of adult chronic diseases such as diabetes, hypertension, dyslipidemia, and cardiovascular disease.
Very-low-birth weight infants present nutritional challenges related to their: A. low ratio of body surface area compared to weight. B. limited ability to digest and absorb fats, carbohydrates, and macro/micronutrients. C. decreased energy needs related to body composition. D. decreased water requirements.
B. VLBW infants have an immature gastrointestinal system, which limits their ability to digest and absorb fats, carbohydrates, macronutrients, and micronutrients. VLBW infants have an increased ratio of surface area to body weight and due to their limited protein and fat stores, have exaggerated energy needs that are specific to their clinical condition, body composition, environmental temperatures and stressors of the NICU environment. They have increased water requirements due to high rates of insensible water losses and their immature renal function. These factors create nutritional challenges and restrict their ability to tolerate high caloric-density formulas due to adverse effects of hyperosmolar solutions.
The nurse should anticipate the tapering of parenteral amino acid intake in the extremely low-birth-weight infant when enteral nutrition reaches how many milliliters per kilogram per day? A. 20 B. 40 C. 75 D. 140
C. A minimum of 75 mL/kg/day of enteral nutrition should be achieved before parenteral amino acids are tapered in the ELBW and VLBW infants. Protein malnutrition can easily develop in this patient population during the transition from parenteral to enteral nutrition. Enteral intake of 20mL/kg/day involves hypocaloric low-volume feeds and does not supply enough enteral protein to warrant parenteral amino acid tapering. A significant part of the enteral protein intake does not reach the systemic circulation and is not immediately available for the growth of other tissues. Enteral intake of 40 mL/kg/day, although greater in volume than trophic feeds, still does not supply enough enteral protein to warrant parenteral amino acid tapering. Enteral intake of 140 mL/kg/day is approaching a full enteral feeding volume, and the infant will most likely not require parenteral nutrition.
A 3-cm increase in abdominal girth, visible bowel loops, increased apnea episodes, and a 50% residual from the infant's last feed is noted upon clinical examination. The nurse should anticipate an order for which type of x-ray? A. Anterior/posterior chest B. Anterior/posterior abdomen C. Anterior/posterior abdomen and cross-table lateral D. Lateral decubitus and anterior/posterior chest
C. Anterior posterior (A/P) abdomen and cross-table films will determine the presence of free air, given the concern for pneumoperitoneum per the clinical examination. Because free air rises, the cross-table lateral has the capability of showing free air positioned just under the abdominal wall. Although a lateral decubitus film will also reveal free air, it requires a high level of skill to position the infant properly. An A/P chest x-ray will reveal pathology of the lings, not the abdomen. An A/P abdominal film is helpful, but may not confirm the presence of free air due to the angle of penetration.
Carbohydrates should supply what percent of an infant's total caloric intake? A. 7-16 B. 25-35 C. 40-50 D. 80-90
C. Carbohydrates are the principal source of energy for the brain and heart and should supply 40%-50% of an infant's total caloric intake. Values less than the recommended amount may result in hypoglycemia. Values higher than the recommended amount may lead to diarrhea and are associated with high-energy diets. Increasing evidence suggests that high-energy diets in the neonatal period have the potential to result in rapid adipose gains and may contribute to obesity, insulin resistance, and type 2 diabetes later in life.
The nurse admitting a 26-week infant who is on high-frequency ventilation and vasopressors is talking with the parents of the infant. The parents would like to start infant massage on their son now. The most appropriate response by the nurse to this request is: A. "Infant massage has shown to have positive effects for preterm infants." B. "Your son is too sick to be touched at this time." C. "Touch is important and your son needs you to make contact with him but massage may be too much stimulation for him at this time." D. "Massage can only be done by a certified infant massage therapist."
C. Current research has shown that infant massage is best utilized for medically stable preterm infants at a variety of gestational ages. At this time their son may be too overstimulated by massage when he is dealing with respiratory and blood pressure problems. The nurse can guide the family to more appropriate types of touch such as facilitated tuck. Infant massage has been demonstrated to have many positive effects in stable preterm infants; currently their son is too unstable for this intervention. The infant, although sick, can have appropriate touch and does need that. It is the nurse and the parents working together who can identify what will be the appropriate type of touch for the infant currently. Massage can be done by parents, health care personnel, and a massage therapist.
Which of the following is true of newborn sleep states? A. Oxygen consumption is lowest during rapid eye movement sleep. B. The best state for interaction with parents is the active alert state. C. Early dominant states are light sleep, quiet sleep, and active alert. D. As the infant matures, less time is spent in the quiet alert state.
C. Early dominant states influence the reaction of a newborn to stimuli and must be taken into account when providing developmentally supportive care. Oxygen consumption is lowest during deep sleep. In the quiet alert state, the infant can maximally attend and respond to parents. Less mature infants spend less time in quiet alert states compared with mature infants.
A 30-week gestation infant who is not physiologically stable will be undergoing a painful procedure. Which of the following techniques can be taught to parents so they can provide developmental support to their baby to reduce pain response behaviors? A. Singing to the baby during the procedure. B. Rapid stroking of the extremities. C. Using their hands to provide flexed containment of the extremities D. Using a soft blanket to maintain gentle extension of the extremities
C. Gentle human touch to provide flexion and containment has a soothing effect. Additional auditory stimulation may be overwhelming. Stroking can result in decreased oxygen saturation and behavioral stress in preterm infants in unstable condition. Human touch is preferable to cloth, and flexion stimulates the in utero position.
A late preterm infant is admitted from the labor and delivery department with grunting, flaring, retractions, and a maternal history of chorioamnionitis. An anterioposterior chest x-ray is immediately obtained and reveals generalized opacity. The nurse should anticipate that the infant is afflicted with which of the following conditions? A. Surfactant deficiency B. Congenital diaphragmatic hernia C. Pneumonia D. Bronchopulmonary dysplasia
C. Given the history of maternal chorioamnionitis and the opacity of the film, pneumonia would be the most likely scenario. Surfactant deficiency would reflect a reticulogranular pattern with air bronchospasms on the x-ray. The film for an infant with congenital diaphragmatic hernia would reveal bowel in the chest with a shifted mediastinum. In contrast, the film for an infant with bronchopulmonary dysplasia would show cystic changes of the lung.
The nurse recognizes that minimal enteral (trophic) feedings with expressed human milk should be initiated at a rate of: A. 5-9 mL/kg/hr. B. 10-20 mL/kg/hr. C. 10-20 mL/kg/day. D. 30-40 mL/kg/day.
C. Minimal enteral feedings should be initiated at a rate of 10-20 mL/kg/day to facilitate postnatal gastrointestinal maturation and to minimize mucosal atrophy. 5-9 mL/kg/hr would be an inappropriate volume for minimal enteral feedings. 10-20 mL/kg/hr would be equivalent to 240-480 ml/kg/day, which would be an inappropriate volume for minimal enteral feedings. A feeding volume of 30-40 mL/kg/day would be representative of advancing enteral nutrition.
Which of the following substrates is the most influential to achieve optimal weight gain for the premature infant? A. Carbohydrate B. Fat C. Protein D. Sodium
C. Proteins are the driving source for weight gain in the premature infant as the major functional and structural components of all human cells. Carbohydrates have been used to augment energy nutrition; however, their benefits do not appear to be independent of protein supply. Additionally, if carbohydrates exceed desirable amounts, glucose polymers can lead to hyperosmolality in the gut lumen., resulting in diarrhea. Fat provides the major source for energy of growing preterm infants; however, the nutritional value of human milk fat may vary with time and does not always provide a complete source of nutrients for premature infants. Sodium is an important electrolyte for cell metabolism, but is not as imperative to growth as protein.
Als' synactive theory provides a framework for understanding preterm behavior. Als identified the autonomic, the motor, and the state systems of the preterm infant. An example of an intervention focused on the motor system is: A. reducing light and sound. B. providing paced feedings. C. providing boundaries or nesting. D. encouraging brief eye contact with the family members at 30 weeks.
C. Providing boundaries can assist with motoric stability such as posture and movement. Reducing light and sound is an intervention that can assist with autonomic stability such as respiratory. Paced feedings is an intervention that can assist with visceral stability of the autonomic subsystem. Eye-to-eye contact can assist with state stability such as awake attention and interaction.
Which is true of noise exposure for premature infants in NICUs? A. A safe range to decrease physiologic stress is 100-110 dB. B. The human voice does not generally exceed the recommended decibel level. C. Increased environmental noise levels are a stressor to all infants, including preterm, term, ill, and well. D. Being inside an incubator sufficiently protects the infant from excessive decibel levels.
C. Recommended noise levels are below 45 dB. Hearing damage occurs in adults at 85 dB. Effects of loud noise affect all infants. Noise increases avoidance behaviors, disturbs sleep, increases cerebral blood flow and intraventricular hemorrhage, increases cardiorespiratory instability, and increases sensorineural hearing loss. The human voice is the greatest contributor to excessive noise in the NICU. Incubators produce internal noise, and the sound of the doors closing is louder on the inside of the incubator.
The nursing plan of care for the growing preterm infant includes approximately how many calories per kilogram per day to sustain adequate energy intake? A. 40 B. 80 C. 120 D. 150
C. The average energy intake for preterm infants to support weight gain is 105-130 kcal/kg/day. 40-80 kcal/kg/day are both lower energy intakes and may not be adequate to support basal metabolism and net protein/fat balance. 150 kcal/kg/day is a higher energy intake and can result in greater fat accumulations and does not enhance neurologic development or achieve proper growth and body composition in comparison to their normal fetal equivalents.
Which statement about the development of the human brain is the most accurate? A. The newborn brain is largely formed by term and is completely developed by 2 years of age. B. Developmental outcome is influenced almost entirely by genetic history, and environmental events have a minimal effect. C. The brain is a chain of communicating cells, and every touch, movement, and emotion affects its wiring and development. D. The brain of a preterm infant at 24 weeks' gestation has many cortical sulci, and these involutions can be harmed by inappropriate stimulation, excessive noise, and repetitive painful stimuli.
C. The brain is a chain of communication cells, and every touch, movement, and emotion affect its wiring and development. The brain triples in size during the first year of life. The quality of brain development is shaped by both genetic history and environmental factors. A very preterm infant (eg, 24 weeks' gestation) has an immature brain structure with a smooth cortex, and few sulci will form during the first year of life.
Sensory development proceeds in a specific order, and stimulation of one system influences other systems. The first sensory system group to develop is: A. auditory/visual. B. olfactory/gustatory. C. tactile/vestibular. D. temperature/pressure.
C. Touch is the first sense to develop at approximately 7.5 weeks of age, and sensitivity to touch is very well developed in the face, lips, and hands. Auditory/visual is the final set of senses to develop. Auditory begins in the second trimester, with visual maturation continuing on for several months postdelivery. Olfactory/gustatory is second set to develop. There is sweet preference present in term and preterm infants, and olfaction is well developed in term and preterm infants. Temperature and pressure are included within the tactile/vestibular domain.
Best practices for a developmentally supportive NICU environment include: A. windows that allow daylight in, use of auditory alarms, and cue-based nursing care. B. continuous fluorescent lighting, placement of pagers on vibrate mode, and provision of non-nutritive sucking. C. day-night cycling of light, avoidance of overhead paging, and rigid timing of nursing care. D. use of a procedure light, use of an acoustical tile, and assessment of stress signals when providing nursing care.
D. Best practices include use of a procedure light to allow for a focused source instead of overhead lighting, use of acoustical tile and visual alarms, avoidance of overhead paging to reduce ambient sound level, and assessment of stress signals when providing nursing care so that the nurse can determine when to stop providing care and let the baby recover, also known as cue-based care timing. Windows that allow daylight in are helpful for staff and family well-being; auditory alarms are to be avoided, because they increase ambient noise and disrupt sleep. Continuous fluorescent lighting can disrupt sleep-wake states. Day-night cycling of light can help decrease levels of stress hormones such as cortisol.
In extremely premature infants, initial enteral feedings of colostrum will result in which of the following? A. Delay induction of many digestive enzymes B. Prohibit the endocytosis of proteins C. Deliver low concentrations of secretory IgA D. Facilitate rapid growth of the intestinal mucosal surface
D. Colostrum contains growth factors, and initial enteral feedings of colostrum in the premature infant stimulates rapid growth in the intestinal mucosa surface area and propagation of many digestive enzymes. It also promotes endocytosis of proteins and delivers high concentrations of secretory IgA.
An abdominal x-ray finding reveals a double bubble. The nurse should anticipate this finding to be indicative of which condition? A. Colonic obstruction B. Meconium ileus C. Pneumoperitoneum D. Duodenal atresia
D. Duodenal atresia is classically seen radiologically as a double bubble as air in the stomach presents as the first bubble and the dilated duodenum filled with air is the second bubble. Colonic obstruction and meconium ileus reflect multiple dilated loops of bowel per abdominal x-ray. Pneumoperitoneum is a large, single, dark area of free air on abdominal x-ray.
Which of the following nutritional deficiencies is associated with poor weight gain, scaling rash, sparse hair growth, thrombocytopenia, and decreased platelet aggregation? A. Zinc deficiency B. Copper deficiency C. Iodine deficiency D. Essential fatty acid deficiency
D. Essential fatty acid deficiency is associated with poor weight gain, scaling rash, sparse hair growth, thrombocytopenia, and decreased platelet aggregation and can be prevented by supplementing exogenous intravenous fat emulsions within 72 hours. Zinc deficiencies can be associated with stunted growth, erythematous skin rash, and increased risk for infections in preterm infants. Copper deficiencies can be associated with poor growth, osteopenia, neutropenia, iron-resistant anemia, pallor, edema, hypotonia, and seborrheic dermatitis. Iodine deficiencies are associated with hypothyroidism, thyroid enlargement, cretinism, poor growth, and increased neonatal and infant mortality.
Developmental care supports sensory integration. Infants born preterm and/or critically ill are at high risk for sensory integration due to the presence of sensory stimulation outside the normal sequence, brain injury, and environmental excesses. An example of appropriate sensory developmental care is: A. introduction of music at 28 weeks' gestation. B. mixing medications with a small amount of feedings before the main feeding. C. education and having parents implement infant massage as soon as possible in order to have them make a "connection" with their infant. D. using indirect lighting or eye covers to protect the infant's eyes if less than 32 weeks' gestation.
D. External stimulation of the visual system should be kept to a minimum. Infants less than 35 weeks have an incompetent pupillary reflex and need their eyes protected from light. Music may be used for infants who are > 32 weeks' gestation and must be a specific type (lullabies) with appropriate monitoring for volume and time interval. Further study is also needed on this topic. Medications should not be mixed with feedings because they alter the taste and may cause rejection of the feeding. This can cause sensory confusion related to negative and pleasurable tastes. Infant massage may be too overstimulating for may preterm or ill infants. Skin-to-skin care is a better option for families to practice. Infant massage may be introduced later when the sensory integration process is more intact for the infant.
Iron deficiency in preterm infants can lead to: A. poor bone mineralization. B. oxidative red blood cell injury and hemolysis. C. poor repair and growth of epithelial tissue. D. anemia and adverse effects on brain development and function.
D. If iron stores are depleted and not available from dietary sources, the infant's hemoglobin will decline and potentially lead to an anemic state. Iron deficiency in preterm infants can also lead to adverse effects on brain development and function. Vitamin D is a fat-soluble vitamin that supports bone mineralization, intestinal calcium, phosphorus absorption, and calcium reabsorption from bone. Vitamin E aids in protecting the red blood cells from oxidative injury and hemolysis. Vitamin A is a fat-soluble vitamin that is needed for repair and growth of epithelial tissue.
Which of the following statements by the nurse would be most appropriate when educating the parents of a 26-week-gestation neonate about the advantages of parenteral nutrition infused through a central line? A. Promotes intestinal growth and maturation B. Decreases the risk of infection C. Minimizes risk of vessel perforation and infiltration D. Allows for delivery of higher concentrations of glucose
D. One advantage of nutrition through a central line is that it permits higher concentrations of intravenous glucose, which may be required to maintain normal plasma glucose and meet glucose demands. Nutrition through a central line is delivered intravenously, which restricts nutrient delivery to the gut and inhibits intestinal growth and maturation. One disadvantage of delivering nutrition through a central line is the risk for infection - a serious and frequent complication. Central lines are at risk for perforation and infiltration.
Core measures for developmental care have been identified and include (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family-centered care, and (5) a healing environment. What is an example of a criterion for developmental activities of daily living? A. All caregiving activities are modified according to the infant's state. B. Physical and auditory privacy is offered at each patient bed space. C. Resources are available 24/7 to support implementation of developmental care. D. Skin assessment is done once per shift and documented.
D. Skin assessment falls under the core measure of developmentally supportive activities of daily living, specifically under the attribute of skin care. Other attributes include positioning and feeding. Caregiving activity modification falls under the protected sleep core measure, under the attribute of care strategies that are individualized for each infant and documented. Physical and auditory privacy falls under the healing environment core measure, under the attribute of a quiet, dimly lit, private environment that promotes safety and sleep. Resource availability for developmental care implementation falls under the healing environment core measure. The attribute is: "Evidence-based policies, procedures, and resources are available to sustain the healing environment over time."
Contraindications to kangaroo care include: A. paternal hair on chest. B. mechanical ventilation. C. maternal preeclampsia requiring magnesium sulfate therapy. D. infection of the skin of the chest of the kangaroo care provider.
D. Skin infection on the chest of the kangaroo care provider could potentially be transmitted to the infant, so kangaroo care should be avoided until skin is clear. There is no evidence that hairy chests cause overheating or infection. All infants should be monitored during kangaroo care, which allows safe administration of conventional mechanical ventilation and/or nasal continuous posiitve airway pressure during kangaroo care. A staff member is needed to attend to the ventilator tubing during transfer to the chest to prevent accidental extubation. Unless the mother is too groggy to feel safe during kangaroo care, maternal preeclampsia requiring magnesium sulfate delivery would not be a contraindication.
The principal parenteral energy source for neural tissue and metabolic processes in an infant weighing less than 1000 grams is intravenous: A. fat emulsion. B. amino acids. C. sodium. D. glucose.
D. The main intravenous energy source for neural tissue and metabolic processes is glucose. The rate of glucose production in neonates weighing less than 1000g is approximately 8-9 mg/kg/min. Intravenous fat emulsions or lipids are important to prevent fatty acid deficiency. Intravenous amino acids are important to achieve protein balance and preserve endogenous protein stores in premature infants. Intravenous sodium is not a source of energy.
The mother of an extremely low-birth-weight infant reports that she is pumping very small amounts of breast milk and asks the nurse about alternative options to maternal breast milk. Which of the following statements is most appropriate for the nurse to share with the mother? A. Human donor milk has the same nutritional properties as maternal breast milk. B. Formula is an option because donor human milk may put the infant at risk for HIV or cytomegalovirus. C. Formula is an option and may decrease the incidence of necrotizing enterocolitis (NEC). D. Donor human milk may decrease the incidence of NEC.
D. The nurse instructs the parents that there is an important advantage to using donor human milk instead of formula, predominately to decrease the incidence of NEC in premature infants. Donor human milk is pasteurized to prevent bacterial and viral contamination; however, pasteurization does change the nutritional and biological quality of donor human milk compared with fresh mother's breast milk. Families can be reassured that human donor milk is safe and that many rules and regulations specify how donor human milk should be collected, screened, stored, and dispensed. Currently, donors are screened to prevent the risk of infection or toxic contamination, and donor human milk is pasteurized to provide microbiological safety. Formula is not a better alternative because evidence suggests that avoiding formula may reduce the incidence of NEC.
Care in the NICU focuses on ways to foster the parent/family as the expert in the relationship with their infant. An example of this fostering would be the nurse: A. telling the parent how to feed their baby. B. having the mother watch the nurse give the first bath. C. making sure the parents are informed of the specific feeding times. D. identifying cues that the parent can use to calm the baby.
D. To have the parent/family be a partner in the care, it is important to help them learn about their baby and how their baby reacts. Identifying cue and clues that they can use to care for their infant helps them gain competency and comfort with their care. Parents can experience and learn alongside the nurse when feedings are done. Parents should be doing all the "firsts" so that common care practices such as bathing are items that they are comfortable doing with minimal assistance. Infant-driven feeding rather than specific feeding times is more conducive to the infant and the family.