Nokea
What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate?
- A. Seizures
- B. Bradycardia
- C. Dysrhythmias
- D. Tetany
Correct Answer: B
Rationale: The infant receiving intravenous calcium gluconate should be monitored for bradycardia.
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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.
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).
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.
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.
The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation?
- A. Administer oxygen via a nasal cannula.
- B. Gently rub the infant's feet or back.
- C. Ventilate with an Ambu bag.
- D. Perform nasopharyngeal suctioning.
Correct Answer: B
Rationale: Gently rubbing the infant's back, ankles, or feet may stimulate the infant to breathe.