Nokea
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.
You may also like to solve these questions
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.
The NICU nurse encourages the mother of a premature neonate to bring breast milk to the unit for enteral feedings to her baby. For which reason does the nurse make this suggestion?
- A. The baby will be more likely to breastfeed later.
- B. The mother will feel more involved with the baby.
- C. The neonate will gain weight faster on breast milk.
- D. Breast milk helps prevent necrotizing enterocolitis.
Correct Answer: D
Rationale: The correct answer is D because breast milk helps prevent necrotizing enterocolitis (NEC) in premature neonates. Breast milk contains protective factors that reduce the risk of NEC, a serious gastrointestinal condition common in preterm infants. Other choices are incorrect: A is not directly related to feeding breast milk, B focuses on emotional involvement rather than physiological benefits, and C does not address the specific health benefits of breast milk in preventing NEC.
Based on the following risk factors, which newborn is least at risk for developing persistent pulmonary hypertension? Select all that apply.
- A. Late or postdates delivery
- B. Born to a mother with gestational diabetes
- C. Appropriate for gestational age
- D. Meconium aspiration
Correct Answer: C
Rationale: The correct answer is C: Appropriate for gestational age. Newborns who are appropriate for gestational age are least at risk for developing persistent pulmonary hypertension because they have not experienced intrauterine growth restriction or other complications that can lead to lung problems. Being born late or postdates (A) can increase the risk of complications, including pulmonary hypertension. Being born to a mother with gestational diabetes (B) can also increase the risk due to potential metabolic issues. Meconium aspiration (D) can lead to respiratory distress and increase the risk of pulmonary hypertension.
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.
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.