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Chapter 13: Preterm and Postterm Newborns/ 100% Verified

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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. ANS: D 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

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