Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this
infant is at risk for what?
a. Skin breakdown
b. Renal failure
c. Brain damage
d. Heart failure
ANS: C
The higher the bilirubin level and the deeper the jaundice, the greater is the risk for
neurological damage.
DIF: Cognitive Level: Comprehension REF: p. 328 OBJ: 4
TOP: Jaundice KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
of Disease
2. How often will the nurse caring for a preterm infant in an incubator record the temperature of the
infant and the incubator?
a. Every hour
b. Every 2 hours
c. Every 4 hours
d. Every 8 hours
ANS: B
The temperature of the incubator is adjusted to a level that will maintain an optimal body
temperature in the infant. Smaller infants may require higher incubator temperatures. The
nurse records the temperature of the infant and the incubator every 2 hours. The infant‘s
temperature is monitored with a heat-sensitive probe that is taped to the abdomen.
, DIF: Cognitive Level: Comprehension REF: p. 329 OBJ: 5
TOP: Thermoregulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. Why is the postterm neonate at risk for cold stress?
a. Inadequate vernix caseosa
b. Hypoxia from a deteriorated placenta
c. Polycythemia
d. Fat stores have been used in utero for nourishment
ANS: D
Fat stores have been used in utero for nourishment during the extended pregnancy.
DIF: Cognitive Level: Comprehension REF: p. 334 OBJ: 9
TOP: Postterm Cold Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8
pounds, 10 ounces. What will the nurse consider this newborn?
a. Term
b. Small for gestational age
c. Large for gestational age
d. Late preterm
ANS: C
Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For
the preterm infant this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for
the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term
infant, is born between 34 and 36 weeks.
DIF: Cognitive Level: Analysis REF: p. 321 OBJ: 2
TOP: Gestational Age KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory
distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function?