Nokea
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
- A. Cleanse skin with a gentle alkaline-based soap and water.
- B. Cleanse skin with a neutral pH solution only when necessary.
- C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
- D. Avoid cleaning skin.
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.
You may also like to solve these questions
Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: Urinary retention in older adults with a neurologic deficit can lead to a behavior change. This change may manifest as increased restlessness, agitation, or discomfort. It is important to be vigilant for any sudden alterations in behavior as they may indicate underlying complications such as urinary retention, which can be more challenging to identify in older individuals who may have difficulty communicating their symptoms clearly. Monitoring for behavior changes can help healthcare providers promptly address and manage urinary retention in these individuals.
A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature ºF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take?
- A. Wrap the neonate warmly and place her in an open crib
- B. Administer an oral glucose feeding of 10% dextrose in water
- C. Increase the temperature setting on the radiant warmer
- D. Obtain an order for IV fluid administration
Correct Answer: A
Rationale: The neonate is likely experiencing hypothermia with an axillary temperature below the normal range for a newborn. The best immediate action is to prevent further heat loss by wrapping the neonate warmly to maintain body temperature. Placing the neonate in an open crib will allow for better monitoring without the heat source of the radiant warmer. It is important to continue monitoring the neonate's temperature closely to ensure it returns to the normal range.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely?
- A. At 1 to 2 years of age
- B. At I week to 1 year of age, peaking at 2 to 4 months
- C. At 6 months to 1 year of age, peaking at 10 months
- D. At 6 to 8 weeks of age
Correct Answer: B
Rationale: Sudden infant death syndrome (SIDS) is most likely to occur between the ages of 1 week to 1 year, with the highest risk period being between 2 to 4 months of age. While SIDS can occur up to the age of 1 year, the peak incidence is during the first 6 months of life. It is important to follow safe sleep practices, such as placing infants on their backs to sleep, to reduce the risk of SIDS during this vulnerable period.
A nurse prepares to administer the medication in which muscle site?
- A. Deltoid
- B. Triceps
- C. Vastus lateralis
- D. Biceps
Correct Answer: C
Rationale: The nurse prepares to administer the medication in the vastus lateralis muscle site. This site is located on the thigh and is commonly used for intramuscular injections in infants, toddlers, and smaller children. It is preferred for its large and easily accessible muscle mass, making it suitable for injections. This muscle site is also less painful and has fewer major blood vessels and nerves, reducing the risk of complications during injection.
A client is admitted to the hospital with a bleeding ulcer and is to receive 4 units of packed cells. Which nursing intervention is of primary importance in the administration of blood?
- A. Checking the flow rate
- B. Monitoring the vital signs
- C. Identifying the client
- D. Maintaining blood temperature
Correct Answer: C
Rationale: The primary nursing intervention in the administration of blood is to correctly identify the client. This is crucial to ensure that the right blood is being administered to the right patient to prevent transfusion reactions and ensure patient safety. Before any blood transfusion, the nurse must verify the patient's identity using at least two unique identifiers, such as name, date of birth, and hospital or medical record number. Patient safety hinges on this critical step, making it the priority when administering blood products. While monitoring vital signs, checking the flow rate, and maintaining blood temperature are all important aspects of blood transfusion management, identifying the client is fundamental and must come first to prevent errors.