Chapter 12: The High-Risk New-born

Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition



MULTIPLE CHOICE

1. What would a nurse assess for in a preterm infant receiving an intravenous infusion
containing calcium gluconate?
a. Seizures
b. Bradycardia
c. Dysrhythmias
d. Tetany


ANS: B
The infant receiving intravenous calcium gluconate should be monitored for
bradycardia.
DIF: Cognitive Level: Application REF: 303 OBJ: 4
TOP: Hypocalcemia KEY: Nursing Process Step: Data Collection


2. What is the rationale for placing a preterm infant born at 34 weeks of gestation under a
radiant warmer?
a. The infant has a small body surface-to-weight ratio.
b. Heat increases the flow of oxygen to the extremities.
c. The infant’s temperature control mechanism is immature.
d. The heat 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 centre in the brain is immature.
DIF: Cognitive Level: Comprehension REF: 300 OBJ: 5
TOP: Thermoregulation KEY: Nursing Process Step:
Implementation

,3. What nursing action is most important to prevent possible retinopathy in a preterm infant
requiring oxygen therapy?
a. Monitor oxygen levels with a pulse oximeter.
b. Position the head slightly lower than the body.
c. Administer low concentrations of oxygen.
d. Keep the infant’s eyes covered at all times.


ANS: A
Use of a pulse oximeter to carefully monitor oxygen saturation in high-risk infants
continues to be a priority in the neonatal intensive care unit.
DIF: Cognitive Level: Application REF: 304 OBJ: 4
TOP: Retinopathy of Prematurity KEY: Nursing Process Step:
Implementation


4. When assessing a preterm infant, a nurse observes nasal flaring, sternal retractions, and
expiratory grunting. What do these findings indicate?
a. Respiratory distress syndrome
b. Postmaturity syndrome
c. Apneic episode
d. Cold stress


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: 298 OBJ: 4
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data
Collection


5. What nursing action will a nurse implement for a preterm infant who is being gavage fed
and has a bloody stool?
a. Assess for abdominal distention.
b. Decrease the amount of the next feeding.
c. Institute enteric precautions.
d. Get a culture of the next stool.

, 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: Application REF: 305 OBJ: 4
TOP: Necrotizing Enterocolitis KEY: Nursing Process Step:
Implementation


6. Parents of a preterm infant come to the NICU every day to see their infant. The infant is
being fed through a gavage tube. What will a nurse teach the parents regarding how to
stimulate the infant?
a. Bring in colourful pictures and toys to place in the isolette.
b. Stimulate the infant during feedings to intake.
c. Stroke the infant during feedings to increase intake.
d. Do not disturb the infant between feedings.


ANS: C
During gavage feedings, stroking the infant gently can provide stimulation.
DIF: Cognitive Level: Application REF: 308 OBJ: 6 | 8
TOP: Developmental Care KEY: Nursing Process Step:
Implementation


7. A nurse is assessing a preterm infant. To what does the infant’s level of maturation refer?
a. Actual time the fetus remained in the uterus
b. Age on the Dubowitz scoring system
c. Infant’s 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: 295 OBJ: 1
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection