16. When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand? 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 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. DIF: Cognitive Level: Analyze REF: p. 818 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 17. When providing an infant with a gavage feeding, which infant assessment should be documented each time? a. Abdominal circumference after the feeding b. Heart rate and respirations before feeding c. Suck and swallow coordination d. Response to the feeding 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. Although vital signs may be obtained before feeding, the infant’s response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infant’s response to the feeding, including the attempts to suck. DIF: Cognitive Level: Apply REF: p. 830 TOP: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 18. An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him 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 at this time? a. Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician b. Continuing to observe and making no changes until the saturations are 75%
c. Continuing with the admission process to ensure that a thorough assessment is completed d. Notifying the parents that their infant is not doing well 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 assist in optimal oxygen saturation of the infant. Oxygen saturation should be maintained above 92%, and oxygenation status of the infant is crucial. 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 determining fetal status.
You've reached the end of your free preview.
Want to read all 548 pages?