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Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?
- A. Hypothermia because of phototherapy treatment
- B. Impaired skin integrity related to diarrhea as a result of phototherapy
- C. Fluid volume deficit related to phototherapy treatment
- D. Knowledge deficit (parents) related to initiation of medical therapy
Correct Answer: C
Rationale: The correct answer is C: Fluid volume deficit related to phototherapy treatment. Priority nursing diagnoses are based on ABCs (Airway, Breathing, Circulation). Fluid volume deficit can result from phototherapy due to increased insensible water loss. This can lead to dehydration and electrolyte imbalances, impacting circulation and overall well-being. Hypothermia (choice A) is important but not the priority in this case. Impaired skin integrity (choice B) is a potential issue but not as critical as fluid volume deficit. Knowledge deficit (choice D) is important for parental education but not an immediate concern compared to fluid balance in the newborn.
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A 3-month-old has pulled out their NG tube at home, and the mother is now speaking with the on-call nurse. What recommendation should the nurse provide her?
- A. drive the infant to the nearest ER
- B. Call 911 and wait for EMS to arrive
- C. attempt to replace the NG tube yourself following discharge training
- D. feed the infant by mouth as there is not an NG tube to use
Correct Answer: C
Rationale: The correct answer is C because the mother was trained on NG tube replacement. This knowledge ensures proper technique and reduces the risk of injury. Driving to the ER or calling 911 may waste time, and feeding by mouth without the NG tube is not safe. Replacing the NG tube at home is the most efficient and appropriate course of action in this scenario.
The nurse is providing support to parents of a premature neonate in NICU. Which actions by the nurse will best provide psychosocial support to the parents? Select all that apply.
- A. Assess the parents’ ability to care for their neonate.
- B. Ask the parents how they are coping with the experience.
- C. Provide equipment for breast pumping and storage of milk.
- D. Provide equipment for breast pumping and storage of milk.
Correct Answer: B
Rationale: The correct answer is B. Asking the parents how they are coping with the experience is crucial for providing psychosocial support. This action shows empathy, encourages open communication, and helps the nurse understand the parents' emotional state. By actively listening, the nurse can offer appropriate support and resources.
Assessing the parents' ability to care for their neonate (Choice A) is important but does not directly address their psychosocial needs. Providing equipment for breast pumping and storage of milk (Choices C and D) is more focused on the physical aspects of care rather than the emotional support needed by the parents.
Which intervention should the nurse instruct the parents to do for their newborn who has acute diaper rash?
- A. Apply the diaper loosely to infant, allowing for better air circulation.
- B. Change the newborn every 4 hours to prevent a moist environment.
- C. Wash the newborn’s diaper area with an antibacterial soap and newborn wipes.
- D. Wipe off the diaper cream thoroughly between diaper changes.
Correct Answer: A
Rationale: The correct answer is A: Apply the diaper loosely to infant, allowing for better air circulation. This is the best intervention for acute diaper rash as it helps reduce moisture and promotes healing. Tight diapers trap moisture, worsening the rash. Choice B is incorrect as changing every 2-3 hours is recommended to maintain a dry environment. Choice C is incorrect as antibacterial soap can be harsh and disrupt the skin's natural flora. Choice D is incorrect as wiping off diaper cream thoroughly can irritate the skin further.
In comparison with the term infant, the preterm infant has
- A. more subcutaneous fat.
- B. well-developed flexor muNscleRs. I G
- C. few blood vessels visible through the skin.
- D. greater surface area in proportion to weight.
Correct Answer: D
Rationale: The correct answer is D: greater surface area in proportion to weight. Preterm infants have a higher surface area to weight ratio due to their smaller size and underdeveloped body systems. This increased surface area makes them more susceptible to heat loss and requires special care to maintain their body temperature.
A: more subcutaneous fat - This is incorrect because preterm infants actually have less subcutaneous fat compared to full-term infants.
B: well-developed flexor muscles - This is incorrect as preterm infants typically have less muscle tone and may exhibit muscle weakness.
C: few blood vessels visible through the skin - This is incorrect as preterm infants often have fragile skin with visible blood vessels due to their underdeveloped skin layers.
Which patient should be assessed first?
- A. Infant with a blood glucose level of 45 mg/dL, maternal history of gestational diabetes
- B. Infant who is plotted on the growth chart between the 75th and 85th percentile for weight and length and the 50th percentile for head circumference
- C. Infant born at 42 weeks gestation to 40-year-old mother who was otherwise healthy during pregnancy and at the time of delivery
- D. Infant born at 38 weeks gestation with a green stain and bruising noted on initial assessment at delivery
Correct Answer: A
Rationale: The correct answer is A. An infant with a blood glucose level of 45 mg/dL and a maternal history of gestational diabetes should be assessed first to rule out hypoglycemia, which can be life-threatening in newborns. Hypoglycemia can lead to seizures, brain damage, or even death if not promptly treated. Infants born to mothers with gestational diabetes are at higher risk for hypoglycemia due to their own insulin production in response to high maternal glucose levels. Therefore, immediate assessment and intervention are crucial.
Choice B is incorrect because growth parameters within normal ranges do not indicate an immediate need for assessment. Choice C is also incorrect as the mother's age and gestational age do not necessarily indicate an urgent need for assessment. Choice D is incorrect as the presence of a green stain and bruising may indicate meconium aspiration syndrome, but hypoglycemia poses a more immediate threat to the infant's health.