Chapter 13: Preterm and Postterm Newborns Nursing School Test Banks

Chapter 13: Preterm and Postterm Newborns

MULTIPLE CHOICE

1. The nurse is assessing a preterm infant. To what does the infants level of maturation refer?
a. Actual time the fetus remained in the uterus
b. Age on the Dubowitz scoring system
c. Infants 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: Page 309 OBJ: 1
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
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 knows that this infant is at risk for what?
a. Skin breakdown
b. Renal failure
c. Brain damage
d. Heart failure
ANS: C
The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage.

DIF: Cognitive Level: Comprehension REF: Page 316 OBJ: 4
TOP: Jaundice KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life?
a. Weak or absent sucking or swallowing reflex
b. Inability to digest food properly
c. Refusal to take formula by mouth
d. Need for a larger quantity of formula at each feeding
ANS: A
When the preterm infants sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.

DIF: Cognitive Level: Comprehension REF: Page 317 OBJ: 4
TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

4. What deficiency causes a preterm infant respiratory distress syndrome?
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: Page 311 OBJ: 4
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

5. How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?
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: Page 317 OBJ: 6
TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

6. The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity?
a. Prostaglandins
b. Oxytocin
c. Magnesium sulfate
d. Corticosteroids
ANS: D
Surfactant production can be increased by administering corticosteroids to the mother before delivery.

DIF: Cognitive Level: Comprehension REF: Page 312 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. What is the most appropriate nursing action in this situation?
a. Administer oxygen via a nasal cannula.
b. Gently rub the infants feet or back.
c. Ventilate with an Ambu bag.
d. Perform nasopharyngeal suctioning.
ANS: B
Gently rubbing the infants back, ankles, or feet may stimulate the infant to breathe.

DIF: Cognitive Level: Application REF: Page 312 OBJ: 4
TOP: Preterm InfantApnea KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate?
a. Seizures
b. Bradycardia
c. Dysrhythmias
d. Tetany
ANS: B
The infant receiving intravenous calcium gluconate should be monitored for bradycardia.

DIF: Cognitive Level: Application REF: Page 314 OBJ: 4
TOP: Hypocalcemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

9. 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 infants 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: Page 314 OBJ: 5
TOP: Thermoregulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy?
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 infants 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: Application REF: Page 315 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. What do these findings indicate?
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: Page 310-311
OBJ: 4 TOP: Respiratory Distress Syndrome
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool?
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.

DIF: Cognitive Level: Application REF: Page 317 OBJ: 4
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. What will the nurse teaching about stimulating the infant 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: Page 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 symptoms indicate what?
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 infants glycogen stores are not adequate.

DIF: Cognitive Level: Analysis REF: Page 314 OBJ: 4
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
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. What is the most appropriate nursing response?
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: Page 320 OBJ: 8
TOP: Preterm Infant KEY: Nursing Process Step: Implementation
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 what is the optimum output for this infant?
a. 1 to 3 mL/kg/hr
b. 4 to 6 mL/kg/hr
c. 7 to 9 mL/kg/hr
d. 10 to 14 mL/kg/hr
ANS: A
The optimum output for a preterm infant is 1 to 3 mL/kg/hr.

DIF: Cognitive Level: Comprehension REF: Page 316 OBJ: 4
TOP: Immature Kidneys KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit?
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: Comprehension REF: Page 309 OBJ: 2
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

18. The nurse in a pediatricians office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth?
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: Page 320 OBJ: 2
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
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. What is the nurses most appropriate response?
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: Page 321 OBJ: 9
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

20. 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
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: Page 314, Nursing Tip
OBJ: 5 TOP: Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk

21. The nurse is caring for an infant born at 43 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
ANS: A
Loss of vernix caseosa leaves the skin dry, causing peeling.

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

22. What term describes the age of a neonate that is based on the actual time in utero?
a. Maturational age
b. Gestational age
c. Neurological age
d. Chronological age
ANS: B
The gestational age is the age based on the actual time in the uterus.

DIF: Cognitive Level: Knowledge REF: Page 309 OBJ: 1
TOP: Gestational Age KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Growth and Development

23. How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator?
a. Every hour
b. Every 2 hours
c. Every 4 hours
d. Every 8 hours
ANS: B DIF: Cognitive Level: Comprehension REF: Page 314
OBJ: 5 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

24. 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
ANS: D
Fat stores have been used in utero for nourishment during the extended pregnancy.

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9
TOP: Postterm Cold Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn?
a. Term
b. Small for gestational age
c. Large for gestational age
d. Late preterm
ANS: C
Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For the preterm infant this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks.

DIF: Cognitive Level: Analysis REF: Page 308-309
OBJ: 1 TOP: Gestational Age
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

26. An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function?
a. Immediately
b. Within 3 days
c. 1 to 2 weeks
d. At least 1 month
ANS: B
In preterm newborns, surfactant can be administered via ET tube at birth or when symptoms of RDS occur, with improvement of lung function seen within 72 hours.

DIF: Cognitive Level: Comprehension REF: Page 312 OBJ: 4
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

27. The nurse knows that a postterm infant may experience which potential problems? (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: Comprehension REF: Page 321 OBJ: 9
TOP: Potential Problems of the Postterm Infant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

28. 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
ANS: A, B, C
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 (in which the placenta lies over the cervix instead of higher in the uterus), and premature separation of the placenta. Studies also indicate the relationships between prematurity and poverty, smoking, alcohol consumption, and abuse of cocaine and other drugs. Hyperemesis gravidarum and chloasma are not risk factors for preterm birth.

DIF: Cognitive Level: Comprehension REF: Page 309 OBJ: 3
TOP: Preterm Birth KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention

29. The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.)
a. Paleness
b. Transparent skin
c. Superficial scalp veins
d. Vomiting
e. Bulging fontanelles
ANS: A, D, E
Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent skin and superficial scalp veins are expected findings.

DIF: Cognitive Level: Application REF: Page 319, Table 13-1
OBJ: 4 TOP: Potential Problems of the Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

30. 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: Knowledge REF: Page 312 OBJ: 2
TOP: Surfactant KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

31. 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: Application REF: Page 320 OBJ: 6
TOP: Stimulation and Feeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

32. 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: Comprehension REF: Page 318, Nursing Care Plan 13-1
OBJ: 4 TOP: Skin Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

33. 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 is when the mother places the infant between her breasts for skin-to-skin contact, and then both mother and infant are wrapped in a blanket as a warming technique. This method also facilitates maternal-infant bonding.

DIF: Cognitive Level: Knowledge REF: Page 317 OBJ: 5 | 7
TOP: Kangaroo Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

34. 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: Page 315 OBJ: 4
TOP: Bleeding Tendency KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk

35. 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: Page 310, Figure 13-2
OBJ: 1 TOP: Ballard Scoring System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

36. Bronchopulmonary dysplasia is the toxic response of the lung to _______ therapy.

ANS:
oxygen

Bronchopulmonary dysplasia is the toxic response of the lung to oxygen therapy.

DIF: Cognitive Level: Knowledge REF: Page 312 OBJ: 1
TOP: Bronchopulmonary Dysplasia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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