Nokea
An infant delivered prematurely at 28 weeks' gestation weighs 1200 g. Based on this information the infant is classified as
- A. SG
- B. VLBW.
- C. ELBW.
- D. low birth weight at term.
Correct Answer: B
Rationale: The correct answer is B: VLBW (Very Low Birth Weight). This classification is based on the infant weighing less than 1500 g at birth, which applies to this scenario as the infant weighs 1200 g. VLBW infants are at higher risk for complications due to their low weight and prematurity.
A: SG (Small for Gestational Age) is incorrect because it refers to infants who are below the 10th percentile for weight at a specific gestational age, not based solely on weight.
C: ELBW (Extremely Low Birth Weight) is incorrect as it typically refers to infants weighing less than 1000 g at birth, which is lower than the infant in this scenario.
D: Low birth weight at term is incorrect as it does not accurately classify a premature infant like the one in the question.
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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 postnatal nurse is providing care for a neonate being treated with phototherapy for hyperbilirubinemia. For which side effects of phototherapy will the nurse contact the neonatal care provider? Select all that apply.
- A. Hyperthermia
- B. Lethargy
- C. Hypocalcemia
- D. Thrombocytopenia
Correct Answer: A
Rationale: The correct answer is A: Hyperthermia. During phototherapy, neonates are at risk for developing hyperthermia due to the heat generated by the lights. The nurse should contact the provider if the neonate shows signs of hyperthermia to prevent complications.
B: Lethargy is not a direct side effect of phototherapy but can be a result of other factors such as inadequate feeding or underlying medical conditions.
C: Hypocalcemia is not a common side effect of phototherapy. It is more often associated with other conditions or treatments.
D: Thrombocytopenia is not a typical side effect of phototherapy. It refers to low platelet levels and is usually not directly related to phototherapy treatment.
The nurse is providing care for a premature neonate in the NICU nursery. The neonate is diagnosed with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA). Which specific intervention does the nurse expect for this neonate?
- A. Monitor of hemoglobin and hematocrit levels.
- B. Obtain blood glucose levels.
- C. Maintain fluid restrictions.
- D. Administer enteral feedings.
Correct Answer: C
Rationale: The correct answer is C: Maintain fluid restrictions. For a neonate with BPD and PDA, fluid restrictions are essential to prevent fluid overload and worsening of the conditions. Excessive fluid can exacerbate pulmonary edema in BPD and increase cardiac workload in PDA. Monitoring hemoglobin and hematocrit levels (A) is important but not specific to these conditions. Obtaining blood glucose levels (B) is important for monitoring overall health but not specific to BPD and PDA. Administering enteral feedings (D) may be necessary but does not directly address the primary concern of fluid management in these conditions.
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 characteristics are typically found in a patient diagnosed with Down syndrome? Select all that apply.
- A. Low-set ears
- B. Broad nasal bridge
- C. Round occiput
- D. Small tongue
Correct Answer: C
Rationale: The correct answer is C: Round occiput. In Down syndrome, individuals often exhibit a round-shaped head at the back (occiput) due to the abnormal growth patterns of the skull bones. This characteristic is a common physical feature seen in individuals with Down syndrome.
A: Low-set ears - While low-set ears can be a feature in some cases of Down syndrome, it is not a defining characteristic and not always present.
B: Broad nasal bridge - Broad nasal bridge is a common feature in Down syndrome, but it is not specific enough to be a defining characteristic.
D: Small tongue - While individuals with Down syndrome may have slightly smaller tongues compared to the general population, it is not a prominent characteristic and not typically used for diagnosis.