Chapter 13: Preterm and Postterm Newborns

1. The nurse assessing a preterm infant understands that the infant's level of maturation refers to: 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. 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. heart failure. ANS: C The higher the bilirubin level and the deeper the jaundice, then greater is the risk for neurological damage. 00:03 01:29 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 infant's sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition. 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. 5. The nurse's 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. 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. 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 a nasal cannula. b. gently rub the infant's feet or back. c. ventilate with an Ambu bag. d. perform nasopharyngeal suctioning. ANS: B Gently rubbing the infant's back, ankles, or feet may stimulate the infant to breathe. 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 intravenous calcium gluconate should be monitored for bradycardia. 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 infant's 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. 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 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 arterial blood gases in high-risk infants continues to be a priority in the neonatal intensive care unit (NICU). 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. 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