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Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?
- A. Group all care activities together to provide long periods of rest.
- B. Keep charts on top of the incubator so the nurses can write on them ther
- C. While giving a report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation.
- D. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
Correct Answer: D
Rationale: The correct answer is D: Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
Rationale:
1. Teaching parents signs of overstimulation empowers them to recognize and respond to their infant's cues effectively.
2. Parents can then modify the environment or interactions to reduce overstimulation, hence decreasing oxygen use.
3. This intervention promotes parental involvement in the care of the preterm infant, fostering a supportive and nurturing environment.
4. By educating parents, the nursing staff can work collaboratively with families to optimize the infant's care and well-being.
Summary:
A: Grouping care activities may help with rest but does not directly address overstimulation and increased oxygen use.
B: Keeping charts on top of the incubator is irrelevant to addressing overstimulation.
C: Providing a soft report does not directly address overstimulation or involve parents in recognizing signs.
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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.
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.
A premature infant has been admitted to the NICU for both respiratory and nutritional support. When should the nurse begin discharge teaching to the family?
- A. after the infant has met goals of a mature breathing pattern and their percentile on the growth chart
- B. as the infant is extubated and transitioned to nasal cannula
- C. when the family shows interest in caring for their neonate independently
- D. as early as possible and throughout the admission
Correct Answer: D
Rationale: The correct answer is D because discharge teaching should start as early as possible and continue throughout the admission to ensure the family receives adequate education and support. Starting early allows for more time to address any concerns, teach necessary skills, and build confidence in caring for the premature infant. This approach promotes better outcomes for both the infant and the family.
Choice A is incorrect because waiting for the infant to meet specific goals may delay essential education and support for the family. Choice B is incorrect as it focuses on a specific medical intervention rather than comprehensive teaching. Choice C is incorrect because interest alone may not indicate readiness or understanding of the care required for a premature infant.
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.
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.