Nokea
The nurse in a pediatrician's office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth?
- A. 1st
- B. 2nd
- C. 3rd
- D. 4th
Correct Answer: B
Rationale: The growth and development of a preterm infant are based on the current age minus the number of weeks before term that the infant was born.
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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.
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.
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.
The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant?
- A. 1 to 3 mL/kg/hr
- B. 4 to 6 mL/kg/hr
- C. 7 to 9 mL/kg/hr
- D. 10 to 14 mL/kg/hr
Correct Answer: A
Rationale: The optimum output for a preterm infant is 1 to 3 mL/kg/hr.
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.