Question 1

Following the vaginal birth of a macrosomic infant, the nurse should assess the infant for:

Accepted Answer

Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to be hypoglycemic. The macrosomic infant would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

Question 2

Which is most helpful in preventing premature birth?

Accepted Answer

Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention. Lower socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC aid in the nutritional status of the pregnant woman, but the most helpful aid for the prevention of premature births is adequate prenatal care.

Question 3

Which nursing action is especially important for an SGA newborn?

Accepted Answer

The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific for SGA infants. Dehydration is a concern for all infants and is not specific for SGA infants. Respiratory distress syndrome is seen in preterm infants.

Question 4

An infant delivered preterm at 28 weeks' gestation weighs 1200 g. Based on this information, the infant is designated as:

Accepted Answer

VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely-low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. However, this option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks' gestation.

Question 5

To determine a preterm infant's readiness for nipple feeding, the nurse should assess the:

Accepted Answer

Coordination of suck, swallow, and breathing is a common task for preterm infants. The infant must have a respiratory rate less than 60 breaths/min before nipple feeding can be implemented; skin turgor, bowel sounds, and current weight are not indications for nipple feeding.

Question 6

In comparison with the term infant, the preterm infant has:

Accepted Answer

Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are more characteristic of a term infant.

Question 7

In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n):

Accepted Answer

Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mmS1U1P13S1S1P0. RBC count ranges from 3.9 to 5.5 million/mL.

Question 8

Which statement is most true about large-for-gestational age (LGA) infants?

Accepted Answer

Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

Question 9

A nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant's color and heart rate remain unchanged. The nurse suspects that the infant:

Accepted Answer

Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths/min). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells.

Question 10

Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?

Accepted Answer

Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for parents but physiologic needs take precedence.

Question 11

An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of:

Accepted Answer

IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the eyes. Other physical characteristics are reported as being normal.

Question 12

Which is true about newborns classified as small for gestational age (SGA)?

Accepted Answer

SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA infants.

Question 13

Decreased surfactant production in the preterm lung is a problem because:

Accepted Answer

Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, it permits better oxygen exchange, but that is not its main purpose.

Question 14

A preterm infant is on a respirator, with intravenous lines and much equipment. When the parents come to visit for the first time, which is an important response by the nurse?

Accepted Answer

Touching the infant will increase the development of attachment. It is important to keep the parents informed about the infant's progress, but the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching but is not the most important priority during the first visit. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant.

Question 15

In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level?

Accepted Answer

ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is caused by rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow. BPD is caused by the use of positive-pressure ventilation against the immature lung tissue.

Question 16

What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction?

Accepted Answer

In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infant's body is long and thin because of lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected because of the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared with the head.

Question 17

Which data should alert the nurse caring for an SGA infant that additional calories may be needed?

Accepted Answer

Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

Question 18

Which preterm infant should receive gavage feedings instead of bottle feedings?

Accepted Answer

Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths/min. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle feeding. Axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min are within expected limits and an indication that the infant is not having respiratory problems at that time.

Question 19

A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is:

Accepted Answer

This post-term infant actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.

Question 20

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?

Accepted Answer

Parents should be taught the signs of overstimulation so they will learn to adapt their care to the needs of their infant. Grouping care activities may understimulate the infant during those long periods and overtire the infant during the procedures. Keeping charts on the incubator and giving the report in front of the incubator may cause overstimulation.

Quiz 29: High-Risk Newborn: Complications Associated with Gestational Age and Development