Nokea
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.
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The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.)
- A. Paleness
- B. Transparent skin
- C. Superficial scalp veins
- D. Vomiting
- E. Bulging fontanelles
Correct Answer: A,D,E
Rationale: Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent skin and superficial scalp veins are expected findings.
What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy?
- 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.
Correct Answer: A
Rationale: 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).
How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?
- 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.
Correct Answer: C
Rationale: 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.
The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of weeks.
Correct Answer: 34
Rationale: Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.
The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.)
- A. Seizures
- B. Asphyxia
- C. Paralysis
- D. Visual defects
- E. Polycythemia
Correct Answer: A,B,E
Rationale: The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.