Nokea
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.
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What deficiency causes a preterm infant respiratory distress syndrome?
- A. Protein
- B. Estrogen
- C. Hyaline
- D. Surfactant
Correct Answer: D
Rationale: The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.
When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. What do these findings indicate?
- A. Respiratory distress syndrome
- B. Postmaturity syndrome
- C. Apneic episode
- D. Cold stress
Correct Answer: A
Rationale: Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.
The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity?
- A. Prostaglandins
- B. Oxytocin
- C. Magnesium sulfate
- D. Corticosteroids
Correct Answer: D
Rationale: Surfactant production can be increased by administering corticosteroids to the mother before delivery.
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.
When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn?
- A. Term
- B. Small for gestational age
- C. Large for gestational age
- D. Late preterm
Correct Answer: C
Rationale: Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA).