Nokea
What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy?
- A. Monitor arterial oxygen levels with a pulse oximeter.
- B. Position the head slightly lower than the body.
- C. Administer low concentrations of oxygen.
- D. Keep the infant's eyes covered at all times.
Correct Answer: A
Rationale: Use of a pulse oximeter to carefully monitor arterial blood gases in high-risk infants continues to be a priority in the neonatal intensive care unit (NICU).
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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.
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.
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.
The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant?
- A. 1 to 3 mL/kg/hr
- B. 4 to 6 mL/kg/hr
- C. 7 to 9 mL/kg/hr
- D. 10 to 14 mL/kg/hr
Correct Answer: A
Rationale: The optimum output for a preterm infant is 1 to 3 mL/kg/hr.
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.