Chapter 13: Preterm and Postterm Newborns Test Bank
MULTIPLE CHOICE
1. The nurse assessing a preterm infant understands that the infant’s level of maturation refers to:
a. actual time the fetus remained in the uterus. b. age on the Dubowitz scoring system.
c. infant’s weight as compared to the gestational age. d. ability of the organs to function outside of the uterus.
ANS: D
Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function outside of the uterus.
DIF: Cognitive Level: Knowledge REF: p. 306 OBJ: 1
TOP: Preterm Infant KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. A preterm infant has a yellow skin color and a rising bilirubin level. The nurse is aware that this infant is at risk for:
a. skin breakdown. b. renal failure. c. brain damage. d. heart failure.
ANS: C
The higher the bilirubin level and the deeper the jaundice, then greater is the risk for neurological damage.
DIF: Cognitive Level: Analysis REF: p. 312 OBJ: 4 TOP: Jaundice KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. The nurse explains that a 4-day-old infant born at 33 weeks of gestation may need to be fed by gavage during the first few days of life because the infant:
a. often has a very weak or absent sucking or swallowing reflex. b. is unable to digest food properly.
c. refuses to take formula by mouth.
d. needs a larger quantity of formula at each feeding. ANS: A
When the preterm infant’s sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.
DIF: Cognitive Level: Comprehension REF: p. 315 OBJ: 4
TOP: Preterm Infant—Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse carefully assesses the preterm infant for respiratory distress syndrome because of a deficiency of: a. protein. b. estrogen. c. hyaline. d. surfactant. ANS: D
The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.
DIF: Cognitive Level: Knowledge REF: p. 307 OBJ: 4
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. The nurse’s safest action to ensure tube placement when preparing to initiate a gavage feeding is to:
a. check tube placement by injecting air into the stomach. b. weigh the infant before the feeding.
c. aspirate stomach contents. d. check serum glucose level.
ANS: C
When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.
DIF: Cognitive Level: Application REF: p. 315 OBJ: 6
TOP: Preterm Infant—Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. The nurse explains that when a preterm delivery is anticipated, fetal lung maturity can be accelerated before delivery by the administration of:
a. prostaglandins. b. oxytocin.
c. magnesium sulfate. d. corticosteroids.
Surfactant production can be increased by administering corticosteroids to the mother before delivery.
DIF: Cognitive Level: Comprehension REF: p. 308 OBJ: 4
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. The apnea monitor indicates that a preterm infant is having an apneic episode. The appropriate nursing action in this situation is to:
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. ANS: B
Gently rubbing the infant’s back, ankles, or feet may stimulate the infant to breathe. DIF: Cognitive Level: Application REF: p. 309 OBJ: 4
TOP: Preterm Infant—Apnea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. When a preterm infant is receiving an intravenous infusion containing calcium gluconate, the nurse would assess this infant for:
a. seizures. b. bradycardia. c. dysrhythmias. d. tetany.
ANS: B
The infant receiving intravenous calcium gluconate should be monitored for bradycardia. DIF: Cognitive Level: Analysis REF: p. 310 OBJ: 4
TOP: Hypocalcemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
9. The nurse clarifies that a preterm infant born at 34 weeks of gestation is placed in an incubator because:
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.
ANS: C
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.
DIF: Cognitive Level: Comprehension REF: p. 310 OBJ: 5
TOP: Thermoregulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10. To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:
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.
ANS: A
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).
DIF: Cognitive Level: Analysis REF: p. 311 OBJ: 4
TOP: Retinopathy of Prematurity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk
11. When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. These findings are indicative of:
a. respiratory distress syndrome. b. postmaturity syndrome. c. apneic episode.
d. cold stress. ANS: A
Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.
DIF: Cognitive Level: Analysis REF: p. 308 OBJ: 4
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. When a preterm infant who is being gavage fed has a bloody stool, the nurse should: a. assess for abdominal distention.
b. decrease the amount of the next feeding. c. institute enteric precautions.
d. get a culture of the next stool. ANS: A
Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.
TOP: Necrotizing Enterocolitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. The nurse teaching about stimulating the infant would tell the parents: a. to bring in colorful pictures and toys to place in the incubator.
b. that stimulating the infant during feedings increases intake. c. to stroke the infant during feeding to increase intake. d. not to disturb the infant between feedings.
ANS: C
During gavage feedings, stroking the infant gently can provide stimulation. DIF: Cognitive Level: Application REF: p. 317 OBJ: 8
TOP: Family Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these are symptoms of:
a. respiratory distress syndrome. b. hypoglycemia.
c. necrotizing enterocolitis. d. renal failure.
ANS: B
The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infant’s glycogen stores are not adequate.
DIF: Cognitive Level: Analysis REF: p. 310 OBJ: 9
TOP: Postterm Infant KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. An appropriate nursing response would be:
a. “Preterm infants usually remain smaller than term infants throughout childhood.” b. “Your daughter will be the same size as other children by the time she is
1-year-old.”
c. “Prematurity is associated with short stature but does not affect weight gain.” d. “It takes about two years for the preterm infant to catch up to a full-term infant.”
ANS: D
In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the second year.
DIF: Cognitive Level: Application REF: p. 317 OBJ: 8
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. The nurse caring for a preterm infant will record the intake and output. The nurse is aware that an optimum output would be _____ mL/kg/hr.
a. 1-3 b. 4-6 c. 7-9 d. 10-14
ANS: A
The optimum output for a preterm infant should be 1-3 mL/kg/hr.
DIF: Cognitive Level: Comprehension REF: p. 311 OBJ: 4
TOP: Immature Kidneys KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17. The nurse is caring for an infant born at 35 weeks of gestation. A physical characteristic that the nurse might expect this infant to exhibit is:
a. thin, long extremities. b. large genitals for its size. c. minimal vernix caseosa. d. loose, transparent skin.
ANS: D
The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.
DIF: Cognitive Level: Analysis REF: p. 306 OBJ: 2
TOP: Preterm Infant KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. The nurse in a pediatrician’s office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. To adjust for the preterm birth, the nurse will evaluate the infant at the level of a ____-month achievement.
a. 1 b. 2 c. 3 d. 4
ANS: B
The growth and development of a preterm infant are based on the current age minus the number of weeks before term that the infant was born.
DIF: Cognitive Level: Analysis REF: p. 317 OBJ: 2
TOP: Preterm Infant KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. The mother of a postterm infant asks the nurse why the infant is being watched so closely. The nurse answers that postterm infants are at risk because:
a. the placenta does not function adequately as it ages. b. infants born postmaturely are generally large. c. delivery of the postterm infant is more difficult. d. there is less amniotic fluid.
ANS: A
Fetal distress may occur in the postterm infant because placental functioning becomes inadequate with maturity.
DIF: Cognitive Level: Comprehension REF: p. 319 OBJ: 9
TOP: Postterm Infant KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The nurse recognizes symptoms of cold stress in a preterm infant as:
tremors and weak cry.
b. plasma glucose level <40 mg/dL. c. warm skin with low core temperature.
d. increased respiratory rate and periods of apnea. ANS: D
Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy.
DIF: Cognitive Level: Comprehension REF: p. 310, Nursing Tip OBJ: 4 TOP: Preterm Infant
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21. The nurse is caring for an infant born at 43 weeks. A physical assessment would reveal: a. dry, peeling skin.
b. minimal hair on the head. c. short, rough nails.
d. abundant lanugo on the body. ANS: A
Loss of vernix caseosa leaves the skin dry, causing peeling.
DIF: Cognitive Level: Comprehension REF: p. 318 OBJ: 9
TOP: Postterm Infant KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. The nurse explains that the age of a neonate that is based on the actual time in utero is the _____ age.
b. gestational c. neurological d. chronological
ANS: B
The gestational age is the age based on the actual time in the uterus.
DIF: Cognitive Level: Knowledge REF: p. 306 OBJ: 1
TOP: Gestational Age KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Growth and Development
23. The nurse caring for a preterm infant in an incubator will record the temperature of the infant and the incubator every:
a. hour. b. 2 hours. c. 4 hours. d. 8 hours.
ANS: B DIF: Cognitive Level: Comprehension REF: p. 314 OBJ: 5 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
24. The nurse explains that the postterm neonate is especially at risk for cold stress due to: a. inadequate vernix caseosa.
b. hypoxia from a deteriorated placenta. c. polycythemia.
d. fat stores have been used in utero for nourishment. ANS: D
Fat stores have been used in utero for nourishment during the extended pregnancy. DIF: Cognitive Level: Application REF: p. 318 OBJ: 9
TOP: Postterm Cold Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
25. The nurse knows that a postterm infant may experience which potential problem(s)? Select all that apply.
a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemia
ANS: A, B, E
The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.
DIF: Cognitive Level: Application REF: p. 318 OBJ: 9 TOP: Potential Problems of the Postterm Infant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
26. The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of _____ weeks.
ANS: 34
Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.
DIF: Cognitive Level: Application REF: p. 308 OBJ: 2 TOP: Surfactant KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27. The nurse providing stimulation to a preterm infant should schedule stimulation not to conflict with __________.
ANS: feeding
Preterm babies should not be stimulated during feeding so they can focus on sucking and swallowing.
DIF: Cognitive Level: Comprehension REF: p. 317 OBJ: 4
TOP: Stimulation and Feeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
28. Assessment of altered skin integrity in the preterm infant is made difficult because of the immature immune system that cannot produce a(n) __________ reaction.
ANS:
inflammatory
The immature immune system cannot produce an inflammatory reaction to show redness or swelling. Without such symptoms, skin integrity is more difficult to assess in the preterm infant.
DIF: Cognitive Level: Application REF: p. 310 OBJ: 4
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
29. The nurse encourages the anxious mother of a preterm infant to consider the warming technique of holding the infant between her breasts with skin-to-skin contact under a blanket. This technique is the __________ care method.
ANS: kangaroo
The kangaroo care method has the mother with the infant placed between her breasts for skin-to-skin contact, and then both wrapped in a blanket as a warming technique.
DIF: Cognitive Level: Application REF: p. 314 OBJ: 5
TOP: Kangaroo Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
30. The nurse is aware that the preterm infant has an increased tendency to bleed due to deficient levels of ________.
ANS: prothrombin
Preterm infants have deficient levels of prothrombin, which increases the tendency to bleed spontaneously.
DIF: Cognitive Level: Knowledge REF: p. 311 OBJ: 4
TOP: Bleeding Tendency KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk
31. The nurse explains that the _____________ ___________ is a tool used to determine the gestational age of a neonate based on appearance and neuromuscular criteria.
ANS:
Ballard Score
The Ballard Score is a standardized method to determine gestational age based on external characteristics and neurological development.
DIF: Cognitive Level: Knowledge REF: p. 306, Figure 13-2 OBJ: 1 TOP: Ballard Scoring System
KEY: Nursing Process Step: Implementation
