Question 1

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient?

Accepted Answer

The caloric concentration of formulas used for preterm infants is usually 22 calories per ounce compared with 20 calories per ounce for a term baby. Glucose water will not provide the infant with adequate calories. Iron supplementation will depend on laboratory values.

Question 2

The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered?

Accepted Answer

Respiratory distress syndrome (RDS) of the newborn most often occurs in preterm infants. Pulmonary surfactant is not present in preterm infant. Surfactant is needed to prevent alveolar collapse upon expiration. RDS rarely occurs in mature infants. Dating a pregnancy by sonogram and by documenting the level of lecithin in surfactant obtained from amniotic fluid exceeds that of sphingomyelin by a 2:1 ratio are both important ways to be certain that an infant is mature enough that RDS is not likely to occur. RDS does not present as bronchial constriction from room air, wheezing from excess fluid accumulation, or inspiratory constriction from air contaminants.

Question 3

Immediately after birth, a preterm infant is placed in a radiant heat warmer. For which nursing diagnosis is this intervention addressing?

Accepted Answer

Placing the preterm infant in a radiant heat warmer is addressing the diagnosis of ineffective thermoregulation related to immaturity. Interventions regarding intake would be appropriate for the diagnosis of risk for imbalanced nutrition. Interventions related to intravenous fluids would be appropriate for the diagnosis of risk for deficient fluid volume. Interventions related to oxygenation would be appropriate for the diagnosis of impaired gas exchange.

Question 4

The nurse manager of a labor and delivery unit is reviewing the skill set needed for the nursing staff to meet the 2020 National Health Goals regarding preterm births. Which skills should the manager validate that the nursing staff has to meet these goals? (Select all that apply.)

Accepted Answer

Nurses can help the nation achieve the 2020 National Health Goals for preterm births by teaching women the symptoms of preterm labor so that birth can be delayed until infants reach term. Nurses also need to be prepared for resuscitation at birth of high-risk infants and to plan developmental care that can help prevent conditions such as apnea and intraventricular hemorrhage. Actions to prevent maternal hypotension would not help achieve the 2020 National Health Goals for preterm labor.

Question 5

The nurse is planning developmental care for a preterm infant in the neonatal intensive care unit. Which interventions should the nurse include in this patient's plan of care? (Select all that apply.)

Accepted Answer

Developmental care for a preterm infant in the neonatal intensive care unit should include audio stimulation, stop procedures at signs of distress, provide a nest of blankets for security, and provide consistent care so sleep/wake cycles develop. Tactile stimulation should be provided by gentle back rubbing or massage. Tickling the feet would be too harsh for this young patient.

Question 6

While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this patient? (Select all that apply.)

Accepted Answer

A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs of obstruction or respiratory compromise in newborns. If these are present, undress the baby's chest and look for intercostal retractions, which reflect the degree of difficulty the newborn is having in drawing in air. Oxygen saturation of 96% is within normal limits and does not indicate respiratory distress.

Question 7

The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?

Accepted Answer

Large-for-gestational age infants need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled, the infant would have had an increased blood glucose level in utero to match the mother's glucose level; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia. Frequent blood glucose monitoring in large-for-gestational-age infants is not done to determine insulin dosage, to explain the effects of maternal hyperglycemia on the baby, or to estimate the amount of calories to provide the infant through formula.

Question 8

A preterm infant is receiving oxygen to maintain respiratory status. When assessing this patient, at which level should the nurse maintain oxygenation to prevent retinopathy of prematurity?

Accepted Answer

When blood Po₂ levels rise to higher than 100 mmHg, the risk of retinopathy of prematurity increases. All preterm infants who receive oxygen must have blood oxygen levels monitored by pulse oximeter, transcutaneous oxygen saturation, or blood gas monitoring so the blood Po₂ level can be kept within normal limits. Oxygenation at 40 mmHg or 50 mmHg is not sufficient for the infant. Oxygenation at 180 mmHg is too high and can predispose the infant to develop retinopathy of oxygenation.

Question 9

The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective?

Accepted Answer

Putting newborns to sleep on the back has decreased the incidence of SIDS by 50% to 60%. Other recommendations to decrease SIDS include using a pacifier, breastfeeding, and having routine immunizations. Removing the pacifier, bottle feeding, and refusing routine immunizations after birth all increase the infant's risk for experiencing SIDS.

Question 10

A preterm infant in the neonatal intensive care unit is receiving care for inadequate fluid balance. What did the nurse assess that supports this nursing diagnosis? (Select all that apply.)

Accepted Answer

An output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. Respiratory rate of 40 breaths/min, heart rate of 135 beats/min, and abdominal skin temperature of 96.9°F are all within normal limits and do not suggest inadequate fluid balance.

Question 11

The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem?

Accepted Answer

Periventricular leukomalacia (PVL) is abnormal formation of the white matter of the brain and is caused by an anoxic episode that interferes with circulation to a portion of the brain. Phagocytes and macrophages invade the area to clear away necrotic tissue. What is left is an abnormality in the white matter of the brain seen as a hollow space. Once the condition has occurred, there is no therapy. Infants may die of the original insult; they may be left with long-term effects such as learning disabilities or cerebral palsy. The parents will need to plan for special care to help with the infant's learning disabilities. The baby does not have an infection. Brain tissue will not grow to fill in the hollow areas. There is no therapy for the condition, and there is no information to support that physical therapy will be beneficial.

Question 12

The nurse is caring for a small-for-gestational-age infant born to a drug-dependent patient. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? (Select all that apply.)

Accepted Answer

Infants of drug-dependent women tend to be small for gestational age. If the patient took a drug close to birth, the infant may show withdrawal symptoms shortly after birth that include tremors, convulsions, high-pitched cry, and constant movement. Respiratory rate would be rapid and not sluggish.

Question 13

The nurse is instructing the parents of a preterm infant about the care the infant will receive within the neonatal intensive care unit. What should the nurse include when teaching the parents at this time? (Select all that apply.)

Accepted Answer

When teaching parents of a newborn in the intensive care unit, the nurse should encourage the parents to bring in a small toy to be placed in the baby's bassinette. The parents should also coordinate the times to visit the baby with the primary nurse so that quality time will be available. The parents should be reminded to ask questions about equipment being used for the baby's care. The name of the primary nurse and primary care provider should be recorded in case the parents have any questions. Telephone calls are encouraged and should not be limited. The parents play an active part in the care of the baby.

Question 14

In which position should the nurse place a newborn to administer oxygen by bag and mask?

Accepted Answer

If a newborn does not draw in a first breath spontaneously following gentle stimulation, place the infant under a radiant heat warmer in a "sniffing" position, which is the head slightly tipped back. Trendelenburg is not a recommended position since this increases intracranial pressure. Flexing the neck could occlude the airway. The position is very important; the tongue will not occlude the airway if the correct position is used.

Question 15

The nurse is preparing to administer surfactant (Survanta) 4 mg/kg every 12 hours for 2 days. The newborn weighs 2,300 g. How many milligram of the medication will the newborn receive for all of the doses? (Numeric value only. Round to the nearest tenth decimal point.)

Accepted Answer

The nurse needs to first convert the baby's weight of 2,300 g to kilogram by dividing by 1,000 or 2,300 / 1,000 = 2.3 kg. Then the nurse is to multiply the prescribed dose of 4 mg × 2.3 kg = 9.2 mg. This is the amount of medication the baby is to receive for each dose. Since the baby is to receive one dose every 12 hours for 2 days or a total of four doses, the nurse would then multiply the single dose amount of 9.2 mg × 4 = 36.8 mg. The baby will receive 36.8 mg of the medication for the total four doses.

Quiz 26: Nursing Care of a Family With a High-Risk Newborn