Preterm Infants

Test your knowledge

1. Choose all that apply when assessing a baby's

readiness to nipple feed.

a. absence of gag reflex

b. ability to tolerate holding

c. rooting

d. sucking

e. respiratory rate >60

Answer: B, C, D

A gag reflex needs to be present. Ability to tolerate holding is a positive sign of readiness, as are rooting, and sucking on a finger, gavage tube, or pacifier. The respiratory rate needs to be less than 60, not more.

(Murray, p. 775)

2.The nurse is developing a plan of care for an infant born at 28 weeks gestation. A realistic goal for this

infant is that within 1 week the infant will

a. recognize parents

b. drink from the bottle

c. maintain respiratory rate between 30 and

60 breaths/min

d. maintain body temperature in a bassinet

Answer:

3.The parent of a pre-term neonate asks why their baby gets cold so easily. The nurse explains that pre-

term neonates

a. “are able to shiver to produce body heat.”

b. “have minimal body fat to retain body heat.”

c. “have blood vessels that are deep under the skin surface.”

d. “lose heat faster because they lay in a fetal position.”

Answer: B

4. A client expresses a desire to breastfeed her pre-term infant who is 34 weeks gestation in the neonatal

intensive care unit. The nurse should?

a. Support the client's decision and encourage her in her efforts of breastfeeding.

b. Tell the client that breast milk is not easily digested.

c. Discourage the client because breastfeeding is stressful for preterm infants.

d. Tell the client the baby is being fed formula by gavage.

Answer: A

Rationale: A nurse should offer support and encouragement to mothers who would like to breastfeed. Breast milk is more easily digested than formula. Breastfeeding is less stressful than bottle-feeding for some preterm infants. If the infant is being fed by gavage the mother can use a breast pump to obtain breast milk and the breast milk can be used for gavage feedings. (Murray page 779-782).

5. A nurse is observing the mother for the infant bonding process. Which of the following observations if made by the nurse would indicate the potential for the lack of the bonding process?

a. Mother is observed talking to the infant.

b. Mother performs cord care for the newborn.

c. Mother requests the nurse to feed the newborn.

d. Mother visits the infant frequently.

Answer: C

Mother requesting the nurse to feed her baby is a sign that bonding is not occurring because the mother is refusing to participate in the care of her infant. The mother talking to her infant shows interest in the infant and is a sign that bonding is occurring. The mother performing cord care is a positive sign that the mother is learning how to care for her baby and is a sign of bonding. Mother visiting her infant frequently is a sign she is concerned about her infant’s well being and care, and bonding is occurring.(Murray, p. 783)

6. With a preterm infant, which position is the best

for increasing oxygenation?

a. Side-lying

b. Supine

c. Prone

d. Supine with lots of fluffy blankets

Answer: C

“In the pre-term infant, the prone position increases oxygenation and lung compliance and decreases energy expenditure” (Murray 2007 p. 767).

7. A 26 week gestation infant is going to receive continuous feeding. What risks are associated?

(Select all that apply)

a. Aspiration

b. Malnutrition

c. Bacteria

d. Reflux

Answer: B, C

Continuous feedings carry a higher risk of aspiration because the infant is not attended at all times during the feeding. In addition, bacteria counts in the milk or formula may become high, and fats tend to adhere to the tubing during continuous feeding (Murray 2007, p. 779).

8. Which of the following would the nurse expect to assess in a infant delivered at 26 weeks gestation who is diagnosed with intraventricular hemorrage

(IVH)?

a. Drainage from eyes

b. Hyperbilirubinemia

c. Bulging fontanels

d. Hyperactivity

Answer: C

Signs of PIVH “may include lethargy, poor muscle tone, deterioration of respiratory status with cyanosis or apnea, drop in hematocrit level, decreased reflexes, full or bulging fontanelle, and seizures. Subtle aberrations of eye position or movement may occur” (Murray, p. 790).

9. A pre-term infant admitted to the NICU at 28 weeks gestation is placed in an isolette. The mother tells the nurse that she is wanting to breastfeed the infant. Which of the following instructions would be

most appropriate? a. Breastfeeding is not recommended because the infant

needs increased fat in the diet

b. Once the infant no longer needs oxygen, breastfeeding can be done.

c. Pre-term infants need the added calories of formula to meet their requirements

d. Gavage feedings using breast milk can be given until the

infant can coordinate sucking and swallowing.

Answer: D

Pre-term infants often are fed parenterally or by gavage initially to conserve energy for growth and basic functioning. During feedings, watch for signs that nipple feeding may soon be possible, such as rooting, respiratory rate below 60, and an increasing ability to tolerate holding and handling. Infants must also have an intact gag reflex or they are more likely to aspirate feedings (Murray 2007, p. 775).

10. When teaching parents about kangaroo care for their premature infant, the nurse would explain that it

is used primarily for

a. freeing up hands to do other activities

b. keeping infants warm

c. providing developmental care

d. a breastfeeding technique

Answer: C

“Kangaroo care provides developmental care that is so important for the preterm infant. It is associated with improved infant growth and decreased length of hospital stay” (Murray, p. 786). Blankets or heat lamps could provide warmth, but the skin to skin contact provides gentle stimulation and increases parent-infant attachment and feelings of confidence in caring for the infant. This method is not a technique for breastfeeding. When caring for a premature infant, the baby requires your full attention, your hands would not be doing other things.

11. The parent's of a 28 week gestation neonate ask the nurse, "Why does our baby have to be fed through a tube in his mouth?" The nurse's best

response is that:

a. “The baby's stomach cannot tolerate regular formula at this time.”

b. “The baby will develop thrush, an infection of the mouth, if it were to bottle feed.”

c. “Only feeding through the tube will allow us to accurately determine intake.”

d. “The baby's sucking, swallowing, and breathing are not coordinated yet.”

Answer: D

Pre-term infants coordination of sucking, swallowing, and breathing at the same time does not happen until the infant

reaches 32 to 34 weeks. (Murray pg 775) 

12. The most common cause of pre-term infant death is respiratory distress, which of the following signs

are not involved in respiratory distress?

a. Bradypnea

b. Nasal flaring

c. Decreased breath sounds

d. Cyanosis

Answer: A

Respiratory distress occurs in about 60% of pre-term infants at 28 weeks gestation. The clinical manifestations that occur within the first hours after birth and they include: Tachypnea, tachycardia, nasal flaring, decreased breath sounds, xiphoid and intercostals retractions, and cyanosis (Murray pg 789)

 

13. What statement would indicate to the nurse that her teaching session about pre-term infant skin care

should be reviewed with the client.

a. “I will not bathe my baby everyday, only when it is necessary.”

b. “I will not dress my baby until she is completely dry.”

c. “I will use an alcohol swab to remove excess tape from my baby's skin.”

d. “I will reposition my infant as often as she can tolerate it.”

Answer: C

“The nurse should avoid the use of chemicals that can injure the skin or may be absorbed through it.  Alcohol should not be used. “(Murray, pg 771)

All other interventions are appropriate according to the textbook.  “Bathing pre-term infants is not necessary on a daily basis and

should be performed only as needed.” (Murray, pg 771)“After the bath the infant should be wrapped in warm towels and

not dressed until thoroughly dry, about 10 minutes.  If the infant is dressed too soon, the clothing will be damp and will increase heat loss.” (Murray, pg 771)

“Frequent position changes are important but should be based on the infant’s ability to tolerate change.” (Murray, pg 771)

14. Which order would the nurse question regarding

care of a pre-term infant?

a. Place infant under radiant warmer for axillary temperature less than 97.3 degrees Fahrenheit.

b. Assess IV site every two hours.

c. Reposition infant every two to three hours to promote draining from the dependent areas of the lungs into the main bronchi.

d. Place transparent adhesive dressing over uninfected wound.

Answer: B

The textbook states that an IV site should be checked every hour.

“IV sites should be assessed at least every hour for signs of infiltration.” (Murray, pg 770)

All other orders are appropriate for a pre-term infant: “The axillary temperature for a pre-term infant should

remain between 97.3°F and 98.4°F.” (Murray, pg 768) “Transparent adhesive dressings may be placed on

uninfected wounds and excoriations but should not be removed daily because the adhesive can further injure the skin.” (Murray, pg 771)

15. The nurse is caring for a pre-term infant. To promote drainage of secretions the nurse would

position the infant:

a. in the Trendelenburg position. b. in the prone position. c. in the supine position. d. in the sitting up position.

Answer: B

In the pre-term infant the prone position increases oxygenation and lung compliance and decreases energy expenditure. The prone position also facilitates drainage of respiratory secretions. The supine position should be used for sleep when infants have recovered enough to tolerate it. The book does not recommend the Trendelenburg or sitting up position to promote drainage. (Murray, p 767)

16. The nurse is caring for a pre-term infant and notes the infant has had urine output > 5 ml/kg/hr, bulging fontanels, edema, and difficulty breathing.

The priority nursing intervention would be:

a. check the fluids and current rate of infusion.

b. perform a complete physical assessment.

c. notify the physician.

d. reassess the client in one hour.

Answer: A

The client is exhibiting signs of over-hydration. The nurse must carefully regulate IV fluids to help prevent fluid volume overload. Performing a complete assessment and notifying the physician are both important, but the priority

is making sure the fluids are infusing at the correct rate. (Murray, p.770)

17. The mother of a pre-term infant is visiting her child in the NICU. She asks if it would be okay to bring her 6 year old twins to visit the new baby. The correct response by the nurse would be

a. “Sure they can come anytime to visit!”

b. “They cannot come and visit the new baby, I'm sorry.”

c. “They may come to visit during times of care, so we do not disturb your baby's rest.”

d. “Let me call the doctor and ask.”

Answer: C

Rationale: Pre-term infants need scheduled quiet periods when lights and noise in the unit are kept at a minimum to promote rest.  Nurses should take care to reduce stimuli for the pre-term infants.  (Murray pg. 774)

18. The mother of a pre-term infant is concerned when her pre-term infant has his hands near his face and mouth. "Won't he scratch himself?" The nurse’s

best response would be:

a. “This brings comfort to your child, and helps with development.”

b. “You’re right, let’s move his hands away from his mouth.”

c. “I will swaddle the baby tightly to keep his hands at his sides.”

d. “It's fine, don't worry about it.”

Answer: A

Rationale: Pre-term infants should have the extremities flexed and the hands placed near the mouth to allow the infant to suck the hands to comfort and for hand to mouth activity which helps with motor development. (Murray pg. 774)

How did you do?

This was only a test. In the case of missing more than 4 questions, we ask that you return to your assigned reading materials of Chapter 29 in the Murray textbook, Foundations of Maternal-Newborn Nursing.