Nokea
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.
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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.
What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate?
- A. Seizures
- B. Bradycardia
- C. Dysrhythmias
- D. Tetany
Correct Answer: B
Rationale: The infant receiving intravenous calcium gluconate should be monitored for bradycardia.
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.
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 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.