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What is the rationale for placing a preterm infant born at 34 weeks of gestation in an incubator?
- A. The infant has a small body surface-to-weight ratio.
- B. Heat increases the flow of oxygen to the extremities.
- C. The infant's temperature control mechanism is immature.
- D. Heat within the incubator facilitates drainage of mucus.
Correct Answer: C
Rationale: The preterm infant is at risk for heat loss for several reasons, one of which is that the heat regulating center in the brain is immature.
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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.
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 nurse knows that a postterm infant may experience which potential problems? (Select all that apply.)
- A. Seizures
- B. Asphyxia
- C. Paralysis
- D. Visual defects
- E. Polycythemia
Correct Answer: A,B,E
Rationale: The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.
When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn?
- A. Term
- B. Small for gestational age
- C. Large for gestational age
- D. Late preterm
Correct Answer: C
Rationale: Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA).
Why is the postterm neonate at risk for cold stress?
- A. Inadequate vernix caseosa
- B. Hypoxia from a deteriorated placenta
- C. Polycythemia
- D. Fat stores have been used in utero for nourishment
Correct Answer: D
Rationale: Fat stores have been used in utero for nourishment during the extended pregnancy.