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.
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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 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.
An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function?
- A. Immediately
- B. Within 3 days
- C. 1 to 2 weeks
- D. At least 1 month
Correct Answer: B
Rationale: In preterm newborns, surfactant can be administered via ET tube at birth or when symptoms of RDS occur, with improvement of lung function seen within 72 hours.
The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of weeks.
Correct Answer: 34
Rationale: Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.
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.
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