Nokea
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.
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A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what?
- A. Skin breakdown
- B. Renal failure
- C. Brain damage
- D. Heart failure
Correct Answer: C
Rationale: The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage.
The nurse is caring for an infant born at 42 weeks. What would the physical assessment reveal?
- A. Dry, peeling skin
- B. Minimal hair on the head
- C. Short, rough nails
- D. Abundant lanugo on the body
Correct Answer: A
Rationale: Loss of vernix caseosa leaves the skin dry, causing peeling.
Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life?
- A. Weak or absent sucking or swallowing reflex
- B. Inability to digest food properly
- C. Refusal to take formula by mouth
- D. Need for a larger quantity of formula at each feeding
Correct Answer: A
Rationale: When the preterm infant's sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.
The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these symptoms indicate what?
- A. Respiratory distress syndrome
- B. Hypoglycemia
- C. Necrotizing enterocolitis
- D. Renal failure
Correct Answer: B
Rationale: The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infant's glycogen stores are not adequate.
The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit?
- A. Thin, long extremities
- B. Large genitals for its size
- C. Minimal vernix caseosa
- D. Loose, transparent skin
Correct Answer: D
Rationale: The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.