Nokea
An infant weight is documented as being in the 90th percentile. What does the RN understand about this measurement?
- A. The infant’s weight is appropriate or average.
- B. The 90th percentile indicates LGA.
- C. Infants in the 90th percentile will be overweight as adults.
- D. The infant’s weight is less than 90% of all other infants’ weights.
Correct Answer: C
Rationale: The correct answer is C because being in the 90th percentile for weight as an infant does not necessarily mean the weight is appropriate or average (choice A) or that the infant is LGA (choice B). Choice D is incorrect because being in the 90th percentile means the infant's weight is greater than 90% of other infants, not less. Choice C is correct because research shows that infants in the 90th percentile for weight are more likely to be overweight as adults due to potential genetic factors and lifestyle habits developed early in life.
You may also like to solve these questions
The nurse notices that a neonate being treated for hyperbilirubinemia with phototherapy has had a daily increase of total bilirubin serum levels greater than 5 mg/dL for the past 2 days. The neonatal care provider prescribes an exchange transfusion. Which knowledge does the nurse apply to the procedure?
- A. The bilirubin indicates a severe hemolytic disease.
- B. Approximately 85% of the neonate’s RBCs are replaced.
- C. Donor RBCs are obtained from the neonate’s mother.
- D. The procedure is exclusive to pathological jaundice.
Correct Answer: A
Rationale: The correct answer is A because a daily increase of total bilirubin levels greater than 5 mg/dL in a neonate being treated for hyperbilirubinemia with phototherapy indicates severe hemolytic disease. This condition requires an exchange transfusion to remove excess bilirubin and replace damaged RBCs. Choice B is incorrect as the percentage of RBCs replaced during an exchange transfusion is closer to 50-60%. Choice C is incorrect as donor RBCs are typically obtained from a blood bank, not the neonate's mother. Choice D is incorrect as an exchange transfusion may be necessary for severe hyperbilirubinemia of various etiologies, not exclusively pathological jaundice.
In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level?
- A. Necrotizing enterocolitis (NEC)
- B. Retinopathy of prematurity (ROP)
- C. Intraventricular hemorrhage (IVH)
- D. Bronchopulmonary dysplasia (BPD)
Correct Answer: C
Rationale: The correct answer is C: Intraventricular hemorrhage (IVH). High arterial blood oxygen levels can lead to IVH in preterm infants due to increased cerebral blood flow and disruption of immature blood vessels in the brain. This can cause bleeding into the brain's ventricles. NEC (A) is more associated with feeding issues, ROP (B) with high oxygen levels, and BPD (D) with prolonged use of mechanical ventilation.
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.
If the neonatal nurse is suspicious of necrotizing enterocolitis in the infant, which intervention should take place first?
- A. Stop feeds
- B. Obtain a blood gas
- C. Call the practitioner
- D. Check electrolytes
Correct Answer: A
Rationale: The correct answer is A: Stop feeds. This is the first intervention because neonatal necrotizing enterocolitis is a serious condition that requires immediate action to prevent further complications. Stopping feeds helps reduce intestinal inflammation and allows the bowel to rest. This step is crucial in managing NEC and preventing perforation. Obtaining a blood gas or checking electrolytes can provide valuable information but are not as urgent as stopping feeds. Calling the practitioner is important but should come after initiating the immediate intervention of stopping feeds.
The newborn is having occasional gasping respirations with a heart rate of 90 beats per minute. Skin color is cyanotic with poor muscle tone. Interpreting relevant clinical data in this scenario, what problems are possible? Select all that apply.
- A. The newborn is hypothermic.
- B. The newborn is full term.
- C. The newborn is experiencing respiratory distress.
- D. The newborn is anemic.
Correct Answer: C
Rationale: The correct answer is C: The newborn is experiencing respiratory distress. Gasping respirations, low heart rate, cyanotic skin, and poor muscle tone are indicative of respiratory distress in a newborn. Gasping is an abnormal breathing pattern seen in severe respiratory distress. A low heart rate is a compensatory response to decreased oxygen levels. Cyanotic skin color indicates poor oxygenation. Poor muscle tone can be a sign of inadequate oxygen delivery to tissues.
Explanation for other choices:
A: The newborn may be hypothermic due to poor temperature regulation, but the primary concern in this scenario is respiratory distress.
B: Being full term does not directly explain the newborn's clinical presentation, so it is not a likely cause.
D: Anemia could contribute to poor oxygen delivery, but the clinical presentation suggests a more acute issue related to respiratory distress.