Chapter 13: Preterm and Postterm Newborns
Multiple Choice
- The nurse assessing a preterm infant understands that the infant's level of maturation refers
to:
- actual time the fetus remained in the uterus.
- age on the Dubowitz scoring system.
- infant's weight as compared to the gestational age.
- 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
- A preterm infant has a yellow skin color and a rising bilirubin level. The nurse is aware that
this infant is at risk for:
- skin breakdown.
- renal failure.
- brain damage.
- 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
- 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: 1 / 2
- often has a very weak or absent sucking or swallowing reflex.
- is unable to digest food properly.
- refuses to take formula by mouth.
- 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
- The nurse carefully assesses the preterm infant for respiratory distress syndrome because of a
deficiency of:
- protein.
- estrogen.
- hyaline.
- 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
- The nurse's safest action to ensure tube placement when preparing to initiate a gavage feeding
is to:
- check tube placement by injecting air into the stomach.
- weigh the infant before the feeding.
- aspirate stomach contents.
- check serum glucose level.
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