Nokea
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?
- A. Immediately
- B. Within 3 days
- C. 1 to 2 weeks
- D. At least 1 month
Correct Answer: B
Rationale: In preterm newborns, surfactant can be administered via ET tube at birth or when symptoms of RDS occur, with improvement of lung function seen within 72 hours.
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What nursing action will the 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.
Correct Answer: A
Rationale: 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.
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
Correct Answer: B
Rationale: The temperature of the incubator is adjusted to a level that will maintain an optimal body temperature in the infant. The nurse records the temperature of the infant and the incubator every 2 hours.
What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid?
- A. Meningitis
- B. Meningocele
- C. Spina bifida occulta
- D. Hydrocephalus
Correct Answer: D
Rationale: Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.
The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation?
- 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.
Correct Answer: B
Rationale: Gently rubbing the infant's back, ankles, or feet may stimulate the infant to breathe.
What symptoms of cold stress might the nurse recognize in a preterm infant?
- A. Tremors and weak cry
- B. Plasma glucose level below 40 mg/dL
- C. Warm skin with low core temperature
- D. Increased respiratory rate and periods of apnea
Correct Answer: D
Rationale: Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy.