Nokea
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.
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A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what?
- A. Skin breakdown
- B. Renal failure
- C. Brain damage
- D. Heart failure
Correct Answer: C
Rationale: The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage.
The nurse is caring for an infant born at 42 weeks. What would the physical assessment reveal?
- A. Dry, peeling skin
- B. Minimal hair on the head
- C. Short, rough nails
- D. Abundant lanugo on the body
Correct Answer: A
Rationale: Loss of vernix caseosa leaves the skin dry, causing peeling.
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.
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.
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.