HESI Case Studies–Premature Infant
1. Which approach should the nurse use in sharing this information with Jamie and her mother?
Discuss the situation with Jamie first and then talk with her mother
2. Jamie asks the nurse why she is receiving the betamethasone. Which response should the nurse give Jamie?
The premature infant’s lungs will function more maturely
3. In anticipation of a premature birth, what should the nurse instruct the student to do? (Place in order from first action through last action)
1. Prepare equipment for resuscitation
2. Cover the scales with a warm blanket
3. Draw up the phytonadione (AquaMEPHYTON)
4. Have the opthalmic erythomycin ointment (Ilosone) available.
4. Labor continues for 12 hours, and a baby boy is delivered vaginally. The nurse places the infant under a radiant warmer and dries him quickly. What is the rationale for this nursing intervention?
Prevent further heat loss
5. Based on this assessment, which Apgar score at 1 minute should the nurse record in the infant’s record?
6. Despite stimulation, the infant continues to have grunting respirations and his skin color becomes dusky. What intervention should the nurse implement next?
Give oxygen by hood
7. Jamie asks the nurse what is causing her infant to have trouble breathing. Which response should the nurse give Jamie?
Lack of surfactant needed to keep alveoli open
8. What intervention should the nurse anticipate being done next?
Adjustment of the ET
9. When Jamie asks the purpose of another tube for her son, what explanation should the nurse provide the mother?
Prevents abdominal distention
10. How should the nurse interpret these blood gas results?
11. Based on the blood gas findings, which intervention should the nurse implement first?
Change the ventilator rate
12. The nurse recognizes which finding(s) consistent with a 30 week premature infant? (Select all)
-The pinna of the ear is flexible and folds forward easily
-Clitoris and labia minora larger than labia majora
13. Twelve hours after delivery, Jamie and her mother visit the NICU. They are upset and crying. How should the nurse respond?
“This must be difficult for you right now.”
14. Which response by the nurse would promote bonding between Jamie and her baby?
“He likes you to talk to him and to touch his hand.”
15. Jamie visit Baby Lamar and asks the nurse, “Why is he off the ventilator and on this new equipment?” Which response should the nurse provide?
“He is breathing on his own, but this equipment provides pressure to help his lungs work better.”
16. Premature infants are at risk for patent ductus arteriosus (PDA). For which early manifestation should the nurse assess Jamie’s son?
Auscultated pulmonary crackles
17. When monitoring for a murmur related to a patent ductus arteriosus, where should the nurse auscultate?
Upper left sternal border
18. To promote closure of a persistent patent ductus arteriosus, the nurse anticipates a prescription for which medication?
19. What change in the infant’s lab values indicates to the nurse that the drug is effective?
Increasing hematocrit and hemoglobin levels
20. The nurse observes the nursing student changing the infant’s diaper by lifting and bending his legs toward his abdomen. Which action should the nurse do next?
Direct the student to change the diapers without bending the infant
21. Premature infants, like Baby Lamar, are at risk for necrotizing enterocolitis (NEC). Which nursing assessment is focused on this risk factor?
Increased gastric residuals
22. Prior to inserting a tube for oral gastric (OG) feedings, what action should the nurse take?
Measure from mouth to ear to xyphoid process
23. While the nurse is giving the gavage feeding by gravity, Baby Lamar’s heart rate goes from 134 to 96. What action should the nurse take?
Pause the feeding by lowering the syringe
24. What primary effect should the nurse observe with the administration of caffeine?
A decrease in apneic events
25. During one feeding session, Baby Lamar goes to sleep after taking only 5mL of the usual 30mL of formula. Jamie tells the nurse that he doesn’t want anymore. Which response should the nurse make?
Premature babies often tire and stop nursing before they get enough. Let me show you how to help him.