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.
b.
c.
recognize parents
drink from the bottle
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 preterm neonates
a.
b.
c.
d.
“are able to shiver to produce body heat.”
“have minimal body fat to retain body heat.”
“have blood vessels that are deep under the skin
surface.”
“lose heat faster because they lay in a fetal position.”
Answer: B
4. A client expresses a desire to breastfeed her preterm infant who is 34 weeks gestation in the neonatal
intensive care unit. The nurse should?
a.
b.
c.
d.
Support the client's decision and encourage her in her
efforts of breastfeeding.
Tell the client that breast milk is not easily digested.
Discourage the client because breastfeeding is stressful
for preterm infants.
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.
b.
c.
d.
Mother is observed talking to the infant.
Mother performs cord care for the newborn.
Mother requests the nurse to feed the newborn.
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.
b.
c.
d.
Side-lying
Supine
Prone
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.
b.
c.
d.
Aspiration
Malnutrition
Bacteria
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.
b.
c.
Drainage from eyes
Hyperbilirubinemia
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.
b.
c.
d.
Breastfeeding is not recommended because the infant
needs increased fat in the diet
Once the infant no longer needs oxygen, breastfeeding
can be done.
Pre-term infants need the added calories of formula to
meet their requirements
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.
b.
c.
d.
freeing up hands to do other activities
keeping infants warm
providing developmental care
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.
b.
c.
d.
“The baby's stomach cannot tolerate regular formula at
this time.”
“The baby will develop thrush, an infection of the
mouth, if it were to bottle feed.”
“Only feeding through the tube will allow us to
accurately determine intake.”
“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.
b.
c.
Bradypnea
Nasal flaring
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.
b.
c.
d.
“I will not bathe my baby everyday, only when it is
necessary.”
“I will not dress my baby until she is completely dry.”
“I will use an alcohol swab to remove excess tape from
my baby's skin.”
“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.
b.
c.
d.
Place infant under radiant warmer for axillary
temperature less than 97.3 degrees Fahrenheit.
Assess IV site every two hours.
Reposition infant every two to three hours to promote
draining from the dependent areas of the lungs into the
main bronchi.
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.
b.
c.
check the fluids and current rate of infusion.
perform a complete physical assessment.
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.
b.
c.
d.
“Sure they can come anytime to visit!”
“They cannot come and visit the new baby, I'm sorry.”
“They may come to visit during times of care, so we do
not disturb your baby's rest.”
“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.
b.
c.
d.
“This brings comfort to your child, and helps with
development.”
“You’re right, let’s move his hands away from his
mouth.”
“I will swaddle the baby tightly to keep his hands at his
sides.”
“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.