Chapter 28: Infants with Gestational Age–Related Problems

Question 1

1. An infant is born to a mother with diabetes after a difficult forceps-assisted birth. After stabilization the infant is weighed, and the birth weight is 4550 g. What is the nurse’s most appropriate action?
   a. Leave the infant in the room with the mother.
   b. Take the infant immediately to the nursery.
   c. Perform a gestational-age assessment to determine whether the infant is large for gestational age.
   d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

Answer 1

ANS: D
This infant is above the ninetieth percentile and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mother’s room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic.

Question 2

2. The nurse knows that infants of mothers with diabetes (IDMs) are at higher risk for developing which problem?
   a. Anemia
   b. Hyponatremia
   c. Respiratory distress syndrome
   d. Sepsis

Answer 2

ANS: C
IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.

Question 3

3. An infant was born 2 hours ago at 37 weeks of gestation. Which blood glucose level would indicate to the nurse that the infant is experiencing hyperglycemia?
   a. 2.3 mmol/L
   b. 3.2 mmol/L
   c. 6.8 mmol/L
   d. 8.6 mmol/L

Answer 3

ANS: D
Hyperglycemia is defined as a blood glucose level greater than 6.9 mmol/L (whole blood) or plasma glucose of 8.0 to 8.3 mmol/L.

Question 4

4. On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they can hold their infant during the next gavage feeding. Given that this newborn is physiologically stable, what is the basis for the nurse’s response?
   a. Parents are not allowed to hold infants who depend on oxygen.
   b. Parents may only hold their baby’s hand during the feeding.
   c. Feedings cause more physiological stress, so the baby must be closely monitored and should not be held by parents.
   d. Parents are encouraged to hold their baby during the feeding.

Answer 4

ANS: D
Parents are encouraged to hold their baby during the feeding; this is an accurate basis for the nurse’s response to the parents’
question. Parental interaction via holding should be encouraged during gavage feedings so that the infant will associate the feeding with positive interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions. The parents can swaddle the infant during gavage feedings to help the infant associate the feeding with positive interactions. Some parents like to do kangaroo care while gavage feeding their infant. Swaddling or kangaroo care during feedings provides positive interactions for the infant.

Question 5

5. A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?
   a. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and
   carbon dioxide.”
   b. “The drug keeps your baby from requiring too much sedation.”
   c. “Surfactant is used to reduce episodes of periodic apnea.”
   d. “Your baby needs this medication to fight a possible respiratory tract infection.”

Answer 5

ANS: A
Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

Question 6

6. When providing an infant with a gavage feeding, which should be documented each time?
   a. The infant’s abdominal circumference after the feeding
   b. The infant’s heart rate and respirations
   c. The infant’s suck and swallow coordination
   d. The infant’s response to the feeding

Answer 6

ANS: D
Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant’s response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infant’s response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infant’s response to the feeding (including attempts to suck).

Question 7

7. An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise?
   a. Rapid bolusing of the entire amount in 15 minutes
   b. Warm cloths to the abdomen for the first 10 minutes
   c. Slow, small, bolus feedings over 30 minutes
   d. Cold, medium bolus feedings over 20 minutes

Answer 7

ANS: C
Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing of the entire amount in 15 minutes would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Warm cloths to the abdomen would not be appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

Question 8

8. An infant at 26 weeks of gestation arrives from the labour and birth unit, intubated. The nurse weighs the infant, places the infant under the radiant warmer, and attaches them to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurse’s most appropriate action?
   a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a pediatric health care provider.
   b. Continue to observe and make no changes until the saturations are 75%.
   c. Continue with the admission process to ensure that a thorough assessment is
   completed.
   d. Notify the parents that their infant is not doing well.

Answer 8

ANS: A
Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to ensure optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92% to 94%. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status.

Question 9

9. A newborn was admitted to the neonatal intensive care unit after being born at 29 weeks of gestation to a 28-year-old multiparous, patient whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth occurred. The newborn’s parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 3 metres away from the bed. What is the nurse’s most appropriate action?
   a. Wait quietly at the newborn’s bedside until the parents come closer.
   b. Go to the parents, introduce themselves, and gently encourage the parents to come
   meet their infant; explain the equipment first, and then focus on the newborn.
   c. Leave the parents at the bedside while they are visiting so they can have some
   privacy.
   d. Tell the parents only about the newborn’s physical condition and caution them to
   avoid touching their baby.

Answer 9

ANS: B
The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents “see” the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant’s condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant’s appearance and condition. Encouragement from the nurse is important in this process. Telling the parents only about the newborn’s physical condition and cautioning them to avoid touching their baby is an inappropriate action.

Question 10

10. Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. What are some of the generalized signs associated with NEC?
    a. Hypertonia, tachycardia, and metabolic alkalosis
    b. Abdominal distension, temperature instability, and grossly bloody stools
    c. Hypertension, absence of apnea, and ruddy skin colour
    d. Scaphoid abdomen, no residual with feedings, and increased urinary output

Answer 10

ANS: B
Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distension, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

Question 11

11. An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant’s mother asks the nurse if her baby will meet developmental milestones on time, as their other child who was born at term. Which is the basis for the nurse’s most appropriate response?
    a. Preterm babies develop at the same rate as term babies.
    b. Preterm babies are not discharged if there are suspicions that there will be
    developmental delays.
    c. Preterm babies need age-corrected ages for developmental assessments.
    d. Preterm babies need to be followed very closely.

Answer 11

ANS: C
The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant’s responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby doesn’t appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time.

Question 12

12. A pregnant woman was admitted for induction of labour at 43 weeks of gestation with sure dates. A nonstress test (NST) revealed an abnormal tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate?
    a. Meconium aspiration, hypoglycemia, and dry, peeling skin
    b. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome
    c. Golden yellow- to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat
    d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

Answer 12

ANS: A
Meconium aspiration, hypoglycemia, and dry, peeling skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with an abnormal NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

Question 13

13. What is the weight designation of an extremely low birth weight (ELBW) infant?
    a. Less than 1500 g
    b. Less than 1000 g
    c. Less than 2000 g
    d. Dependent on the gestational age

Answer 13

ANS: B
At a weight of less than 1000 g, problems are so numerous that ethical issues regarding when to treat arise. The designation for very low birth rate is less than 1500 g; ELBW is less than 1000 g. A weight of less than 2000 g is less than low but too high for extremely low, which is less than 1000 g. Gestational age is a factor with weight in the condition of the preterm birth, but it is not part of the birth weight categorization.

Question 14

14. In the continuing assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. What should the nurse suspect?
    a. Hypovolemia and/or shock
    b. A non-neutral thermal environment
    c. Central nervous system injury
    d. Pending renal failure

Answer 14

ANS: A
The nurse should suspect hypovolemia and/or shock. Other symptoms might include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary

Question 15

15. Which is reflected when premature infants exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respirations?
    a. They are suffering from sleep or wakeful apnea.
    b. They are experiencing severe swings in blood pressure.
    c. They are trying to maintain a neutral thermal environment.
    d. They are breathing in a respiratory pattern common to premature infants.

Answer 15

ANS: D
This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.

Question 16

16. What should the nurse know with regard to appraising the growth and development potential of a preterm infant?
    a. Tell the parents that their child won’t catch up until about age 10 (girls) to 12
    (boys).
    b. Correct for milestones such as motor competencies and vocalizations until the
    child is approximately 3 years of age.
    c. Know that the greatest catch-up period is between 9 and 15 months
    postconceptual age.
    d. Know that the length and breadth of the trunk is the first part of the infant to
    experience catch-up growth.

Answer 16

ANS: B
Corrections are made with a formula that adds gestational age and postnatal age. The infant, girl or boy, experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks postconceptual age. The head is the first to experience catch-up growth.

Question 17

17. The nurse practising in the perinatal setting should promote kangaroo care, regardless of an infant’s gestational age. What should the nurse know about this intervention?
    a. It is adopted from classical British nursing traditions.
    b. It helps infants with motor and central nervous system impairment.
    c. It enhances their temperature regulation.
    d. It gets infants ready for breastfeeding.

Answer 17

ANS: C
Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent’s bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.

Question 18

18. For clinical purposes, preterm and postterm infants are defined as
    a. preterm before 34 weeks if appropriate for gestational age (AGA); before 37
    weeks if small for gestational age (SGA).
    b. postterm after 40 weeks if large for gestational age (LGA); beyond 42 weeks if
    AGA.
    c. preterm before 37 weeks, postterm beyond 42 weeks, no matter the size for
    gestational age at birth.
    d. preterm, SGA before 38 to 40 weeks; postterm, LGA beyond 40 to 42 weeks.

Answer 18

ANS: C
Preterm and postterm are strictly measures of time—before completion of 37 weeks and beyond 42 completed weeks, respectively—regardless of size for gestational age.

Question 19

19. What should nurses be aware of with regard to small-for-gestational-age (SGA) infants and intrauterine growth restrictions (IUGR)?
    a. In the first trimester, diseases or abnormalities result in asymmetrical IUGR.
    b. Infants with asymmetrical IUGR have the potential for normal growth and
    development.
    c. In asymmetrical IUGR weight will be slightly more than SGA, whereas length
    and head circumference will be somewhat less than SGA.
    d. Symmetrical IUGR occurs in the later stages of pregnancy.

Answer 19

ANS: B
IUGR is either symmetrical or asymmetrical. The symmetrical form occurs in the first trimester; SGA infants have reduced brain capacity. The asymmetrical form occurs in the later stages of pregnancy. Weight is less than the tenth percentile; head circumference is greater than the tenth percentile. Infants with asymmetrical IUGR have the potential for normal growth and development

Question 20

20. With regard to eventual discharge of the high-risk newborn or transfer to a different facility, which should nurses and families be aware of?
    a. Infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home.
    b. Once discharged to home, the high-risk infant should be treated like any healthy term newborn.
    c. Parents of high-risk infants need special support and detailed contact information.
    d. If a high-risk infant and mother need transfer to a specialized regional centre, it is
    better to wait until after birth and the infant is stabilized.

Answer 20

ANS: C
High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high-risk infants are discharged does not mean that they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

Question 21

21. To develop an optimal plan of care for this infant, the nurse must understand that which intervention has the greatest effect on lowering the risk of necrotizing enterocolitis (NEC)?
    a. Early enteral feedings
    b. Breastfeeding
    c. Exchange transfusion
    d. Prophylactic probiotics

Answer 21

ANS: B
Breast milk is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes. The neonatal intensive care unit nurse can be supportive of the mother in terms of providing her with equipment to pump, ensuring privacy, and encouraging skin-to-skin contact. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Systemic antibiotic therapy should be instituted rather than prophylactic probiotics.

Question 22

22. While evaluating the plan that has been implemented for a preterm infant, which indicates that the infant is experiencing cold stress?
    a. Decreased respiratory rate
    b. Bradycardia followed by an increased heart rate
    c. Apnea and hypoglycemia
    d. Increased physical activity

Answer 22

ANS: C
The infant has minimal-to-no fat stores. During times of cold stress, apnea and hypoglycemia are often present. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse’s role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases, followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

Question 23

23. An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of
    a. birth injury.
    b. hypocalcemia.
    c. hypoglycemia.
    d. seizures.

Answer 23

ANS: C
Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

Question 24

24. When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has
    a. few blood vessels visible through the skin.
    b. more subcutaneous fat.
    c. well-developed flexor muscles.
    d. greater surface area in proportion to weight.

Answer 24

ANS: D
Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

Question 25

25. In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?
    a. Necrotizing enterocolitis (NEC)
    b. Retinopathy of prematurity (ROP)
    c. Bronchopulmonary dysplasia (BPD)
    d. Intraventricular hemorrhage (IVH)

Answer 25

ANS: B
ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

Question 26

26. An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment?
    a. Extracorporeal membrane oxygenation
    b. Respiratory support with a ventilator
    c. Insertion of a laryngoscope and suctioning of the trachea
    d. Insertion of an endotracheal tube

Answer 26

ANS: A
Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, thus allowing the infant’s lungs to rest and recover. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath. An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation.

Question 27

27. Which infant is at highest risk of neurological birth injuries?
    a. Preterm infant born at 35 weeks of gestation.
    b. Appropriate-for-gestational age (AGA) infant born at 42 weeks of gestation.
    c. Very-low-birth-weight (VLBW) infant born at 36 weeks of gestation.
    d. Intrauterine growth restriction (IUGR) infant born at 39 weeks of gestation.

Answer 27

ANS: C
Neurological injury in newborn infants is common with the increased survival of low-birth-weight (LBW) and VLBW infants; in addition, the lower the gestational age, the higher the risk for certain neurological injuries.

Question 28

1. Which are signs of stress or fatigue in a newborn? (Select all that apply.)
   a. Hypoflexion
   b. Tachypnea
   c. Tremors
   d. Regular respirations
   e. Gape face
   f. Hypertonicity

Answer 28

ANS: B, C, E, F
The newborn experiencing stress of fatigue exhibits tachypnea, tremors, gape face, and hypertonicity. Also seen is hyperflexion and irregular respirations.

Question 29

2. Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply.)
   a. problems with thermoregulation.
   b. cardiac distress.
   c. hyperbilirubinemia.
   d. sepsis.
   e. hyperglycemia.

Answer 29

ANS: A, C, D
Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge the infant is at risk for rehospitalization related to these problems. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.