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A preterm infant is on a ventilator, with intravenous lines and other medical equipment. When the parents come to visit for the first time, what is the most important action by the nurse?
- A. Encourage the parents to touch their infant.
- B. Reassure the parents that the infant is progressing well.
- C. Discuss the care they will give their infant when the infant goes hom
- D. Suggest that the parents visit for only a short time to reduce their anxiety.
Correct Answer: A
Rationale: The correct answer is A: Encourage the parents to touch their infant. This is important as physical touch promotes bonding between the parents and the infant, which is crucial for the infant's emotional and psychological development. It also helps the parents feel connected and involved in the care of their child.
Choice B is incorrect because reassurance alone may not address the parents' need for physical closeness and bonding with their infant. Choice C is incorrect as discussing future care at this moment may overwhelm the parents and distract from the immediate need for bonding. Choice D is incorrect because limiting the parents' visit time may create more anxiety and hinder the bonding process.
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The nurse is present in the delivery room when a mother is told her neonate was stillborn. The mother begins to wail loudly and pull at her hair. Which action does the nurse take?
- A. Allow the mother to express grief in her own way.
- B. Attempt to calm the mother and prevent self-harm.
- C. Ask for a sedative to calm the mother’s reaction.
- D. Ask a family member to comfort the mother.
Correct Answer: A
Rationale: The correct answer is A: Allow the mother to express grief in her own way. The nurse should prioritize the mother's emotional needs by providing a safe space for her to express her grief. This can help the mother process her emotions and begin the grieving process. Option B may come across as dismissive of the mother's feelings and could hinder her emotional healing. Option C with sedatives may suppress the mother's natural grieving process and is not recommended unless absolutely necessary. Option D is not appropriate as the nurse should be present to support the mother directly.
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 sign will the newborn experiencing respiratory obstruction often exhibit first?
- A. Gagging
- B. Vomiting
- C. Decreased heart rate
- D. Increased respiratory rate
Correct Answer: D
Rationale: The correct answer is D: Increased respiratory rate. When a newborn experiences respiratory obstruction, they will initially exhibit an increased respiratory rate as their body tries to compensate for the lack of oxygen. This is a natural response to try to increase oxygen intake. Gagging (choice A) and vomiting (choice B) may occur as secondary symptoms if the obstruction persists. Decreased heart rate (choice C) is unlikely to be the first sign, as the body typically prioritizes ensuring oxygen supply to vital organs such as the brain. Therefore, the increased respiratory rate is the most immediate and crucial sign to indicate respiratory obstruction in a newborn.
The nurses in a NICU are concerned about the appropriate levels of oxygen therapy during the care of premature neonates. The nurses referenced an article by Newman (2014) titled, “Oxygen Saturation Limits and Evidence supporting the Targets.” On which evidence-based conclusion will the nurses develop guidelines?
- A. Oxygen saturation limits of 85% to 89% are effective.
- B. Oxygen saturation rates of 91% to 95% are effective.
- C. Infants are within saturation limits about 75% of the time.
- D. Oxygen saturation limits need to be between 87% to 94%.
Correct Answer: B
Rationale: The correct answer is B: Oxygen saturation rates of 91% to 95% are effective. This range is supported by the article by Newman (2014) as the optimal oxygen saturation levels for premature neonates. Here's the rationale:
1. The range of 91% to 95% falls within the typical target range for oxygen saturation in premature neonates, ensuring adequate oxygenation without the risk of hyperoxia or hypoxia.
2. Maintaining oxygen saturation within this range has been shown to improve outcomes and reduce the risk of complications in premature neonates.
3. The article by Newman likely provides evidence-based research supporting this specific range as the most effective for neonatal care.
In summary, choices A, C, and D are incorrect because they do not align with the evidence-based optimal oxygen saturation range for premature neonates as supported by the referenced article.
A newborn assessment finding that would support the nursing diagnosis of postmaturity would be
- A. loose skin.
- B. ruddy skin color.
- C. presence of vernix.
- D. absence of lanugo.
Correct Answer: A
Rationale: The correct answer is A: loose skin. Postmaturity in newborns is characterized by dry, cracked, and peeling skin due to prolonged gestation. Loose skin is a classic sign of postmaturity, indicating reduced subcutaneous fat. Ruddy skin color (B) is not specific to postmaturity. Vernix (C) is present in newborns and decreases with gestational age, not directly related to postmaturity. Lanugo (D) is fine hair that covers a fetus and sheds before birth, not a specific indicator of postmaturity.