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The nurse in NICU is assessing a neonate delivered at 32 weeks gestation. Which pathophysiological manifestation is the nurse’s greatest concern?
- A. Absent or weak reflexes
- B. Presence of a heart murmur
- C. Apnea 20 seconds or longer
- D. Low hemoglobin lab level
Correct Answer: C
Rationale: The correct answer is C: Apnea 20 seconds or longer. In a neonate delivered at 32 weeks gestation, apnea lasting 20 seconds or longer is the greatest concern as it indicates immature respiratory control and potential for respiratory distress or failure. Absent or weak reflexes (A) may be common in premature infants but are not as critical as respiratory issues. A heart murmur (B) may be present due to structural heart defects, but apnea poses a more immediate threat. Low hemoglobin (D) may indicate anemia, which can be managed with appropriate interventions, unlike compromised respiratory function.
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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.
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.
Which infant is at greatest risk for developing hypoglycemia after birth?
- A. Severe small for gestational age infant
- B. Appropriate for gestational age infant
- C. Infant of a diabetic mother with maternal glucose control
- D. Cold-stressed term infant
Correct Answer: A
Rationale: The correct answer is A: Severe small for gestational age (SGA) infant, as they have limited glycogen stores and are at higher risk for hypoglycemia. SGA infants often have poor growth in utero, leading to decreased nutrient reserves. This puts them at increased risk for low blood sugar levels after birth.
Incorrect choices:
B: Appropriate for gestational age infants typically have adequate glycogen stores and are at lower risk for hypoglycemia.
C: Infants of diabetic mothers with good maternal glucose control are less likely to have hypoglycemia due to stable blood sugar levels in utero.
D: Cold-stressed term infants may have transient hypoglycemia, but they are not at the greatest risk compared to severe SGA infants.
Which is the most common etiology for pathological jaundice in an infant?
- A. ABO incompatibility
- B. Physiological
- C. Inherited pathology
- D. Birth trauma
Correct Answer: A
Rationale: The correct answer is A: ABO incompatibility. This is the most common etiology for pathological jaundice in an infant because it occurs when the baby's blood type is incompatible with the mother's, leading to the destruction of the baby's red blood cells and subsequent release of bilirubin, causing jaundice. Physiological jaundice (B) is common but typically resolves on its own without treatment. Inherited pathologies (C) such as genetic conditions may cause jaundice, but they are less common than ABO incompatibility. Birth trauma (D) can lead to jaundice in rare cases, but it is not the most common etiology.
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.