Nokea
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.
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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 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.
What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid?
- A. Meningitis
- B. Meningocele
- C. Spina bifida occulta
- D. Hydrocephalus
Correct Answer: D
Rationale: Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.
The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity?
- A. Prostaglandins
- B. Oxytocin
- C. Magnesium sulfate
- D. Corticosteroids
Correct Answer: D
Rationale: Surfactant production can be increased by administering corticosteroids to the mother before delivery.
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).