An infant delivered prematurely at 28 weeks' gestation weighs 1200 g. Based on this information the infant is classified as
- A. SG
- B. VLBW.
- C. ELBW.
- D. low birth weight at term.
Correct Answer: B
Rationale: The correct answer is B: VLBW (Very Low Birth Weight). This classification is based on the infant weighing less than 1500 g at birth, which applies to this scenario as the infant weighs 1200 g. VLBW infants are at higher risk for complications due to their low weight and prematurity.
A: SG (Small for Gestational Age) is incorrect because it refers to infants who are below the 10th percentile for weight at a specific gestational age, not based solely on weight.
C: ELBW (Extremely Low Birth Weight) is incorrect as it typically refers to infants weighing less than 1000 g at birth, which is lower than the infant in this scenario.
D: Low birth weight at term is incorrect as it does not accurately classify a premature infant like the one in the question.
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Which sign will the newborn experiencing respiratory obstruction often exhibit first?
- A. Gagging
- B. Vomiting
- C. Decreased heart rate
- D. Increased respiratory rate
Correct Answer: D
Rationale: The correct answer is D: Increased respiratory rate. When a newborn experiences respiratory obstruction, they will initially exhibit an increased respiratory rate as their body tries to compensate for the lack of oxygen. This is a natural response to try to increase oxygen intake. Gagging (choice A) and vomiting (choice B) may occur as secondary symptoms if the obstruction persists. Decreased heart rate (choice C) is unlikely to be the first sign, as the body typically prioritizes ensuring oxygen supply to vital organs such as the brain. Therefore, the increased respiratory rate is the most immediate and crucial sign to indicate respiratory obstruction in a newborn.
The postnatal nurse is providing care for a neonate being treated with phototherapy for hyperbilirubinemia. For which side effects of phototherapy will the nurse contact the neonatal care provider? Select all that apply.
- A. Hyperthermia
- B. Lethargy
- C. Hypocalcemia
- D. Thrombocytopenia
Correct Answer: A
Rationale: The correct answer is A: Hyperthermia. During phototherapy, neonates are at risk for developing hyperthermia due to the heat generated by the lights. The nurse should contact the provider if the neonate shows signs of hyperthermia to prevent complications.
B: Lethargy is not a direct side effect of phototherapy but can be a result of other factors such as inadequate feeding or underlying medical conditions.
C: Hypocalcemia is not a common side effect of phototherapy. It is more often associated with other conditions or treatments.
D: Thrombocytopenia is not a typical side effect of phototherapy. It refers to low platelet levels and is usually not directly related to phototherapy treatment.
Based on the following risk factors, which newborn is least at risk for developing persistent pulmonary hypertension? Select all that apply.
- A. Late or postdates delivery
- B. Born to a mother with gestational diabetes
- C. Appropriate for gestational age
- D. Meconium aspiration
Correct Answer: C
Rationale: The correct answer is C: Appropriate for gestational age. Newborns who are appropriate for gestational age are least at risk for developing persistent pulmonary hypertension because they have not experienced intrauterine growth restriction or other complications that can lead to lung problems. Being born late or postdates (A) can increase the risk of complications, including pulmonary hypertension. Being born to a mother with gestational diabetes (B) can also increase the risk due to potential metabolic issues. Meconium aspiration (D) can lead to respiratory distress and increase the risk of pulmonary hypertension.
Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?
- A. Hypothermia because of phototherapy treatment
- B. Impaired skin integrity related to diarrhea as a result of phototherapy
- C. Fluid volume deficit related to phototherapy treatment
- D. Knowledge deficit (parents) related to initiation of medical therapy
Correct Answer: C
Rationale: The correct answer is C: Fluid volume deficit related to phototherapy treatment. Priority nursing diagnoses are based on ABCs (Airway, Breathing, Circulation). Fluid volume deficit can result from phototherapy due to increased insensible water loss. This can lead to dehydration and electrolyte imbalances, impacting circulation and overall well-being. Hypothermia (choice A) is important but not the priority in this case. Impaired skin integrity (choice B) is a potential issue but not as critical as fluid volume deficit. Knowledge deficit (choice D) is important for parental education but not an immediate concern compared to fluid balance in the newborn.
In comparison with the term infant, the preterm infant has
- A. more subcutaneous fat.
- B. well-developed flexor muNscleRs. I G
- C. few blood vessels visible through the skin.
- D. greater surface area in proportion to weight.
Correct Answer: D
Rationale: The correct answer is D: greater surface area in proportion to weight. Preterm infants have a higher surface area to weight ratio due to their smaller size and underdeveloped body systems. This increased surface area makes them more susceptible to heat loss and requires special care to maintain their body temperature.
A: more subcutaneous fat - This is incorrect because preterm infants actually have less subcutaneous fat compared to full-term infants.
B: well-developed flexor muscles - This is incorrect as preterm infants typically have less muscle tone and may exhibit muscle weakness.
C: few blood vessels visible through the skin - This is incorrect as preterm infants often have fragile skin with visible blood vessels due to their underdeveloped skin layers.