Nokea
The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. What is the most appropriate nursing response?
- A. Preterm infants usually remain smaller than term infants throughout childhood.'
- B. Your daughter will be the same size as other children by the time she is 1 year old.'
- C. Prematurity is associated with short stature but does not affect weight gain.'
- D. It takes about two years for the preterm infant to catch up to a full-term infant.'
Correct Answer: D
Rationale: In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the second year.
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The 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
Correct Answer: D
Rationale: 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.
Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching about stimulating the infant tell the parents?
- A. To bring in colorful pictures and toys to place in the incubator
- B. That stimulating the infant during feedings increases intake
- C. To stroke the infant during feeding to increase intake
- D. Not to disturb the infant between feedings
Correct Answer: C
Rationale: During gavage feedings, stroking the infant gently can provide stimulation.
What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate?
- A. Seizures
- B. Bradycardia
- C. Dysrhythmias
- D. Tetany
Correct Answer: B
Rationale: The infant receiving intravenous calcium gluconate should be monitored for bradycardia.
The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm delivery? (Select all that apply.)
- A. Placenta previa
- B. Gestational diabetes
- C. Pregnancy-induced hypertension
- D. Hyperemesis gravidarum
- E. Chloasma
Correct Answer: A,B,C
Rationale: The predisposing causes of preterm birth are numerous; in many instances, the cause is unknown. Prematurity may be caused by multiple births, illness of the mother (e.g., malnutrition, heart disease, diabetes mellitus, or infectious conditions), or the hazards of pregnancy itself, such as gestational hypertension, placental abnormalities that may result in premature rupture of the membranes, placenta previa, and premature separation of the placenta.
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.