Question 1

Which data should alert the nurse that the neonate is postmature?
A) Cracked, peeling skin
B) Short, chubby arms and legs
C) Presence of vernix caseosa
D) Presence of lanugo

Accepted Answer

Cracked, peeling skin is a sign of postmaturity as it indicates that the baby has been in the womb for a long time and the protective layer of vernix caseosa has worn off, leading to dry skin. Short, chubby arms and legs (B) are not indicative of postmaturity but may be a sign of a well-nourished baby. Presence of vernix caseosa (C) and presence of lanugo (D) are both signs of immaturity and would not be present in a postmature baby.

Question 2

What will the nurse note when assessing an SGA infant with asymmetric intrauterine growth restriction?
A) One side of the body appears slightly smaller than the other.
B) All body parts appear proportionate.
C) The head seems large compared with the rest of the body.
D) The extremities are disproportionate to the trunk.

Accepted Answer

In asymmetric intrauterine growth restriction, the head is typically spared and appears larger compared to the rest of the body, which is smaller due to restricted growth.

Question 3

Which combination of expressing pain could be demonstrated in a neonate?
A) Low-pitched crying, tachycardia, eyelids open wide
B) Cry face, flaccid limbs, closed mouth
C) High-pitched, shrill cry, withdrawal, change in heart rate
D) Cry face, eye squeeze, increase in blood pressure

Accepted Answer

These manifestations are indicative of pain in the neonate.Cry and an increased heart rate are manifestations of neonatal pain.Typically,infants close their eyes tightly when in pain,not open them wide.Infants may cry in response to pain.Additionally,they may display a rigid posture with the mouth open.A high-pitched,shrill cry is associated with genetic/neurologic anomalies.The infant may cry,withdraw limbs,and become tachycardic with pain.

Question 4

What nursing action is especially important for the SGA newborn?
A) Observe for respiratory distress syndrome.
B) Observe for and prevent dehydration.
C) Promote bonding.
D) Prevent hypoglycemia by early and frequent feedings.

Accepted Answer

SGA (small for gestational age) newborns are at risk for hypoglycemia due to decreased glycogen stores and reduced ability to produce glucose. It is important to prevent hypoglycemia by initiating early and frequent feedings. Observing for respiratory distress syndrome and preventing dehydration are also important nursing actions, but prevention of hypoglycemia takes priority in SGA newborns. Bonding is also important, but it is not specific to the care of SGA newborns.

Question 5

Of all the signs seen in infants with respiratory distress syndrome,which sign is especially indicative of the syndrome?
A) Pulse more than 160 beats/min
B) Circumoral cyanosis
C) Grunting
D) Substernal retractions

Accepted Answer

Grunting is especially indicative of respiratory distress syndrome, as it is a reflexive action that infants use to try to maintain their airways and keep their lungs inflated. The other signs listed can also be present in infants with respiratory distress syndrome, but they are not as specific or unique to the condition as grunting.

Question 6

Which statement is true about large for gestational age (LGA)infants?
A) They weigh more than 3500g.
B) They are above the 80th percentile on gestational growth charts.
C) They are prone to hypoglycemia, polycythemia, and birth injuries.
D) Postmaturity syndrome and fractured clavicles are the most common complications.

Accepted Answer

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

Question 7

While caring for the postterm infant,the nurse recognizes that the fetus may have passed meconium prior to birth as a result of
A) Hypoxia in utero
B) NEC
C) Placental insufficiency
D) Rapid use of glycogen stores

Accepted Answer

Hypoxia in utero can cause fetal distress and as a result, the fetus may pass meconium in the amniotic fluid.

Question 8

Decreased surfactant production in the preterm lung is a problem because surfactant
A) Causes increased permeability of the alveoli
B) Provides transportation for oxygen to enter the blood supply
C) Keeps the alveoli open during expiration
D) Dilates the bronchioles, decreasing airway resistance

Accepted Answer

Surfactant is a substance produced by the lungs that coats the inside of the alveoli and helps to keep them open during expiration. Without surfactant, the alveoli can collapse and make it harder for oxygen to enter the bloodstream.

Question 9

With regard to eventual discharge of the high risk newborn or transfer to a different facility,nurses and families should be aware that
A) Infants will stay in the NICU until they are ready to go home.
B) Once discharged to home, the high risk infant should be treated like any healthy term newborn.
C) Parents of high risk infants need special support and detailed contact information.
D) If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

Accepted Answer

Parents of high risk infants need special support and detailed contact information to ensure proper care in the home setting. This may include access to resources and follow-up appointments with specialists. It is important for nurses to provide this support and information to the family before discharge.

Question 10

A premature infant never seems to sleep longer than an hour at a time.Each time a light is turned on,an incubator closes,or people talk near her crib,she wakes up and cries inconsolably until held.The correct nursing diagnosis is ineffective coping related to
A) Severe immaturity
B) Environmental stress
C) Physiologic distress
D) Behavioral responses

Accepted Answer

The infant's inability to sleep for longer than an hour at a time and her tendency to wake up and cry when exposed to different environmental stimuli suggest that she is experiencing environmental stress. This can be a common issue in premature infants who have yet to develop their ability to filter out external stimuli, and can cause them to demonstrate signs of ineffective coping such as difficulty sleeping or responding negatively to environmental changes.

Question 11

Overstimulation may cause increased oxygen use in a preterm infant.Which nursing intervention helps to avoid this problem?
A) Group all care activities together to provide long periods of rest.
B) While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation.
C) Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
D) Keep charts on top of the incubator so the nurses can write on them there.

Accepted Answer

Teaching the parents signs of overstimulation allows them to identify when their infant is becoming overstimulated and take necessary actions to reduce it. This can help prevent increased oxygen use and other negative consequences. Grouping care activities together and standing in front of the incubator to talk softly do not directly address the issue of overstimulation. Keeping charts on top of the incubator may be convenient but does not directly address the issue at hand.

Question 12

Because of the premature infant's decreased immune functioning,what nursing diagnosis should the nurse include in a plan of care for a premature infant?
A) Delayed growth and development
B) Ineffective thermoregulation
C) Ineffective infant feeding pattern
D) Risk for infection

Accepted Answer

Premature infants have a decreased immune functioning, which puts them at a higher risk for infection. Therefore, the nursing diagnosis of "Risk for infection" should be included in the plan of care for a premature infant. Delayed growth and development, ineffective thermoregulation, and ineffective infant feeding pattern may also be issues for premature infants, but they are not specifically related to their decreased immune functioning.

Question 13

What is most helpful in preventing premature birth?
A) High socioeconomic status
B) Adequate prenatal care
C) Transitional Assistance to Needy Families
D) Women, Infants, and Children nutritional program

Accepted Answer

Adequate prenatal care has been shown to greatly reduce the risk of premature birth. Prenatal care allows healthcare providers to identify and manage any potential medical issues early on, reducing the risk of complications that could lead to premature birth. While factors such as high socioeconomic status and access to nutritional programs can also contribute to maternal and fetal health, they are not as directly focused on preventing premature birth as adequate prenatal care.

Question 14

Compared to the term infant,the preterm infant has
A) Few blood vessels visible though the skin
B) More subcutaneous fat
C) Well-developed flexor muscles
D) Greater surface area in proportion to weight

Accepted Answer

Preterm infants have less body mass and are therefore relatively larger in surface area compared to term infants.

Question 15

The preterm infant who should receive gavage feedings instead of a bottle is the one who
A) Sometimes gags when a feeding tube is inserted
B) Is unable to coordinate sucking and swallowing
C) Sucks on a pacifier during gavage feedings.
D) Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

Accepted Answer

The preterm infant who is unable to coordinate sucking and swallowing should receive gavage feedings instead of a bottle. Gavage feedings involve the insertion of a feeding tube directly into the stomach, bypassing the need for the infant to coordinate sucking, swallowing, and breathing. This is often necessary for preterm infants who have not yet developed these skills or who tire easily during feeding. Gagging when a feeding tube is inserted or sucking on a pacifier during gavage feedings does not necessarily mean that the infant cannot coordinate sucking and swallowing. The vital signs listed in option D may indicate illness, but do not provide information about the infant's ability to feed.

Question 16

Which is true about newborns classified as small for gestational age (SGA)
A) They weigh less than 2500  g.
B) They are born before 38 weeks of gestation.
C) Placental malfunction is the only recognized cause of this condition.
D) They are below the 10th percentile on gestational growth charts.

Accepted Answer

Small for gestational age (SGA) newborns are defined as those whose birth weight is below the 10th percentile for their gestational age. This means that they are smaller than 90% of babies of the same gestational age. This does not necessarily mean that they were born before 38 weeks of gestation or that placental malfunction was the only cause of their growth restriction.

Question 17

In caring for the preterm infant,what complication is thought to be a result of high arterial blood oxygen level?
A) Necrotizing enterocolitis (NEC)
B) Retinopathy of prematurity (ROP)
C) Bronchopulmonary dysplasia (BPD)
D) Intraventricular hemorrhage (IVH)

Accepted Answer

Retinopathy of prematurity (ROP) is a complication seen in premature infants who have had high levels of arterial blood oxygen. This can cause abnormal growth of blood vessels in the retina, leading to scarring and ultimately vision loss.

Question 18

Late preterm infants need closer monitoring during her hospital stay than term infants.In order to prevent unrecognized cold-stress the nurse should perform all except
A) Wean the infant to an open crib.
B) Check temperature every 3 to 4 hours.
C) Encourage kangaroo care.
D) Place infant on a radiant warmer.

Accepted Answer

Weaning the infant to an open crib too soon can increase the risk of cold stress, as late preterm infants may not be able to maintain their body temperature as effectively as term infants.

Question 19

To maintain optimal thermoregulation for the premature infant,the nurse should
A) Bathe the infant once a day.
B) Put an undershirt on the infant in the incubator.
C) Assess the infant's hydration status.
D) Lightly clothe the infant under the radiant warmer.

Accepted Answer

The answer of To maintain optimal thermoregulation for the premature...

Question 20

An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time.It is important for the nurse to
A) Suggest that the parents visit for only a short time to reduce their anxieties.
B) Reassure the parents that the baby is progressing well.
C) Encourage the parents to touch her.
D) Discuss the care they will give her when she goes home.

Accepted Answer

Encouraging the parents to touch the infant will help promote bonding and attachment, as well as provide comfort and reassurance to the infant. It is important for the parents to feel involved in their child's care, even if she is on a respirator and surrounded by equipment. Short visits may not allow enough time for bonding to occur, and discussing care for the future may not be as relevant at this stage. Reassurances should be given, but encouraging touch should be the priority.

Quiz 29: The High-Risk Newborn: Problems Related to Gestational Age and Development

Which data should alert the nurse that the neonate is postmature?

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

Which combination of expressing pain could be demonstrated in a neonate?

What nursing action is especially important for the SGA newborn?

Of all the signs seen in infants with respiratory distress syndrome,which sign is especially indicative of the syndrome?

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

While caring for the postterm infant,the nurse recognizes that the fetus may have passed meconium prior to birth as a result of

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

With regard to eventual discharge of the high risk newborn or transfer to a different facility,nurses and families should be aware that

A premature infant never seems to sleep longer than an hour at a time.Each time a light is turned on,an incubator closes,or people talk near her crib,she wakes up and cries inconsolably until held.The correct nursing diagnosis is ineffective coping related to

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

Because of the premature infant's decreased immune functioning,what nursing diagnosis should the nurse include in a plan of care for a premature infant?

What is most helpful in preventing premature birth?

Compared to the term infant,the preterm infant has

The preterm infant who should receive gavage feedings instead of a bottle is the one who

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

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

Late preterm infants need closer monitoring during her hospital stay than term infants.In order to prevent unrecognized cold-stress the nurse should perform all except

To maintain optimal thermoregulation for the premature infant,the nurse should

An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time.It is important for the nurse to