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What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool?
- A. Assess for abdominal distention.
- B. Decrease the amount of the next feeding.
- C. Institute enteric precautions.
- D. Get a culture of the next stool.
Correct Answer: A
Rationale: Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.
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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.
How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?
- A. Check tube placement by injecting air into the stomach.
- B. Weigh the infant before the feeding.
- C. Aspirate stomach contents.
- D. Check serum glucose level.
Correct Answer: C
Rationale: When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.
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.
The nurse in a pediatrician's office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth?
- A. 1st
- B. 2nd
- C. 3rd
- D. 4th
Correct Answer: B
Rationale: The growth and development of a preterm infant are based on the current age minus the number of weeks before term that the infant was born.
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.