Nokea
The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement?
- A. Align the limbs.
- B. Support the head.
- C. Keep the head lower than the hip.
- D. Check intake and output.
Correct Answer: B
Rationale: The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be supported when feeding and moving the child to prevent injury to the neck.
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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.
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.
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.
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 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.