Chapter 13: Preterm and Postterm Newborns My Nursing Test Banks

Chapter 13: Preterm and Postterm Newborns

Elsevier items and derived items 2007 by Saunders, an imprint of Elsevier Inc.

MULTIPLE CHOICE

1. The nurse assessing a preterm infant understands that the infants level of maturation refers to:

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

ANS: D

Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function outside of the uterus.

DIF: Cognitive Level: Knowledge REF: 305 OBJ: 1

TOP: Preterm Infant KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

2. A preterm infant has a yellow skin color and a rising bilirubin level. The nurse is aware that this infant is at risk for:

a.

Skin breakdown

b.

Renal failure

c.

Brain damage

d.

Congestive heart failure

ANS: C

The higher the bilirubin level and the deeper the jaundice, the greater the risk for neurological damage.

DIF: Cognitive Level: Analysis REF: 311 OBJ: 4

TOP: Jaundice KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The nurse explains that a 4-day-old infant born at 33 weeks of gestation may need to be fed by gavage during the first few days of life because the infant:

a.

Often has a very weak or absent sucking or swallowing reflex

b.

Is unable to digest food properly

c.

Refuses to take formula by mouth

d.

Needs a larger quantity of formula at each feeding

ANS: A

When the preterm infants sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.

DIF: Cognitive Level: Comprehension REF: 312 OBJ: 5

TOP: Preterm Infant-Nutrition KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

4. The nurse carefully assesses the preterm infant for respiratory distress syndrome because of a deficiency of:

a.

Protein

b.

Estrogen

c.

Hyaline

d.

Surfactant

ANS: D

The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.

DIF: Cognitive Level: Knowledge REF: 305 OBJ: 4

TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

5. The nurses safest action to ensure tube placement when preparing to initiate a gavage feeding is to:

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

ANS: C

When the preterm infant is gavage-fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.

DIF: Cognitive Level: Application REF: 315 OBJ: 5

TOP: Preterm Infant-Nutrition KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

6. The nurse explains that when a preterm delivery is anticipated, fetal lung maturity can be accelerated before delivery by the administration of:

a.

Prostaglandins

b.

Oxytocin

c.

Magnesium sulfate

d.

Corticosteroids

ANS: D

Surfactant production can be increased by administering corticosteroids to the mother before delivery.

DIF: Cognitive Level: Comprehension REF: 306 OBJ: 4

TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

7. The apnea monitor indicates that a preterm infant is having an apneic episode. The appropriate nursing action in this situation is to:

a.

Administer oxygen via nasal cannula

b.

Gently rub the infants feet or back

c.

Ventilate with an Ambu bag

d.

Perform nasopharyngeal suctioning

ANS: B

Gently rubbing the infants back, ankles, or feet may stimulate the infant to breathe.

DIF: Cognitive Level: Application REF: 308 OBJ: 4

TOP: Preterm Infant-Apnea KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. When a preterm infant is receiving an intravenous infusion containing calcium gluconate, the nurse would assess this infant for:

a.

Seizures

b.

Bradycardia

c.

Dysrhythmias

d.

Tetany

ANS: B

The infant receiving IV calcium gluconate should be monitored for bradycardia.

DIF: Cognitive Level: Analysis REF: 309 OBJ: 4

TOP: Hypocalcemia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

9. The nurse clarifies that a preterm infant born at 34 weeks of gestation is placed in an incubator because:

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.

ANS: C

The preterm infant is at risk for heat loss for several reasons, one of which is that the heat-regulating center in the brain is immature.

DIF: Cognitive Level: Comprehension REF: 310 OBJ: 6

TOP: Thermoregulation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

a.

Monitor arterial oxygen levels with a pulse oximeter

b.

Position with the head slightly lower than the body

c.

Administer low concentrations of oxygen

d.

Keep the infants eyes covered at all times

ANS: A

Use of a pulse oximeter to carefully monitor arterial blood gases in high-risk infants continues to be a priority in the NICU.

DIF: Cognitive Level: Analysis REF: 310 OBJ: 4

TOP: Retinopathy of Prematurity KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

11. When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. These findings are indicative of:

a.

Respiratory distress syndrome

b.

Postmaturity syndrome

c.

Apneic episode

d.

Cold stress

ANS: A

Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.

DIF: Cognitive Level: Analysis REF: 307-308 OBJ: 4

TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. When a preterm infant who is being gavage-fed has a bloody stool, the nurse should:

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

ANS: A

Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.

DIF: Cognitive Level: Analysis REF: 310 OBJ: 4

TOP: Necrotizing Enterocolitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

13. Parents of a preterm infant come to the NICU every day to see their baby, who is being gavage-fed. The nurse would include in the teaching about stimulating their infant to:

a.

Bring in colorful pictures and toys to place in the incubator.

b.

Stimulate the baby during feedings to increase intake.

c.

Give the baby a pacifier during gavage feedings.

d.

Do not disturb the infant between feedings.

ANS: C

During gavage feedings, a pacifier may be used to provide nonnutritive sucking.

DIF: Cognitive Level: Application REF: 315 OBJ: 9

TOP: Family Reaction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

14. The nurse caring for an infant born at 43 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these are symptoms of:

a.

Respiratory distress syndrome

b.

Hypoglycemia

c.

Necrotizing enterocolitis

d.

Renal failure

ANS: B

The postterm infant, born after 42 weeks, should be assessed for hypoglycemia. Postmaturity may have depleted the infants glycogen reserves, leading to hypoglycemia.

DIF: Cognitive Level: Analysis REF: 309 OBJ: 9

TOP: Postterm Infant KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

15. The parent of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. An appropriate nursing response would be:

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 goes to kindergarten.

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.

ANS: D

In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term baby by about the second year.

DIF: Cognitive Level: Application REF: 315 OBJ: 1

TOP: Preterm Infant KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

16. The nurse caring for a preterm infant will record the intake and output. The nurse is aware that an optimum output would be:

a.

8 to 11.5 ml/hr

b.

12 to 13.5 ml/hr

c.

14 to 16 ml/hr

d.

17 to 19 ml/hr

ANS: D

The optimum output for a preterm infant should be 3 ml/kg/hr. A 3-pound baby is 6.6 kilograms.

DIF: Cognitive Level: Analysis REF: 311 OBJ: 4

TOP: Immature Kidneys KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The nurse is caring for an infant born at 35 weeks of gestation. A physical characteristic that the nurse might expect this infant to exhibit is:

a.

Thin, long extremities

b.

Large genitals for its size

c.

Lanugo on the back and abdomen

d.

Loose, transparent skin

ANS: D

The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.

DIF: Cognitive Level: Analysis REF: 305 OBJ: 2

TOP: Preterm Infant KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

18. 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. To adjust for the preterm birth, the nurse will evaluate the infant at the level of a _____ achievement.

a.

1-month

b.

2-month

c.

3-month

d.

4-month

ANS: B

The growth and development of a preterm infant are based on the current age minus the number of weeks before term that the infant was born.

DIF: Cognitive Level: Analysis REF: 315 OBJ: 2

TOP: Preterm Infant KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

19. The mother of a postterm infant asks the nurse why the baby is being watched so closely. The nurse answers that postterm infants are at risk because:

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.

ANS: A

Fetal distress may occur in the postterm infant because placental functioning becomes inadequate with maturity.

DIF: Cognitive Level: Comprehension REF: 316 OBJ: 9

TOP: Postterm Infant KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

20. The nurse recognizes symptoms of cold stress in a preterm infant as:

a.

Tremors and weak cry

b.

Plasma glucose level <40 mg/dl

c.

Warm skin with low core temperature

d.

Increased respiratory rate and periods of apnea

ANS: D

Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy.

DIF: Cognitive Level: Comprehension REF: 309 OBJ: 4

TOP: Preterm Infant KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

21. The nurse is caring for an infant born at 43 weeks. A physical assessment would reveal:

a.

Dry, peeling skin

b.

Minimal hair on the head

c.

Short, rough nails

d.

Abundant lanugo on the body

ANS: A

Loss of vernix caseosa leaves the skin dry, causing peeling.

DIF: Cognitive Level: Comprehension REF: 317 OBJ: 9

TOP: Postterm Infant KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

MULTIPLE RESPONSE

1. The nurse reviews the potential problems a postmature infant may experience, such as:

Select all that apply.

a.

Seizures

b.

Asphyxia

c.

Paralysis

d.

Visual defects

e.

Polycythemia

ANS: A, B, E

The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.

DIF: Cognitive Level: Application REF: 317 OBJ: 9

TOP: Potential Problems of the Postterm Infant

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

COMPLETION

1. The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of ____________________ weeks.

ANS: 34

DIF: Cognitive Level: Application REF: 306 OBJ: 2

TOP: Surfactant KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

NOT: Rationale: Surfactant begins to appear at the age of 24 weeks, and is adequate to support life at the age of 32 weeks.

2. The nurse providing stimulation to a preterm infant should schedule stimulation so as not to conflict with ____________________.

ANS: feeding

DIF: Cognitive Level: Comprehension REF: 316 OBJ: 5

TOP: Stimulation and Feeding KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

NOT: Rationale: Preterm babies need to be unstimulated during feeding so they can focus on sucking and swallowing.

3. Assessment of altered skin integrity in the preterm infant is made difficult because of the immature immune system that cannot produce an ____________________ reaction.

ANS: inflammatory

DIF: Cognitive Level: Application REF: 315 OBJ: 2

TOP: Skin Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

NOT: Rationale: The immature immune system cannot produce an inflammatory reaction to show redness or swelling. Without such symptoms, skin integrity is more difficult to assess in the preterm infant.

4. The nurse encourages the anxious mother of a preterm infant to consider the warming technique of holding the baby between her breasts with skin-to-skin contact under a blanket. This technique is the ____________________ care method.

ANS: kangaroo

DIF: Cognitive Level: Application REF: 314 OBJ: 6

TOP: Kangaroo Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

NOT: Rationale: The kangaroo care method has the mother with the infant placed between her breasts for skin-to-skin contact, and then both wrapped in a blanket as a warming technique.

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