Nokea
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.
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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 term describes the age of a neonate that is based on the actual time in utero?
- A. Maturational age
- B. Gestational age
- C. Neurological age
- D. Chronological age
Correct Answer: B
Rationale: The gestational age is the age based on the actual time in the uterus.
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 mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the nurse's most appropriate response?
- A. The placenta does not function adequately as it ages.'
- B. Infants born postmaturely are generally large.'
- C. Delivery of the postterm infant is more difficult.'
- D. There is less amniotic fluid.'
Correct Answer: A
Rationale: Fetal distress may occur in the postterm infant because placental functioning becomes inadequate with maturity.
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.