Nokea
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.
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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.
An infant delivered prematurely at 28 weeks' gestation weighs 1200 g. Based on this information the infant is classified as
- A. SG
- B. VLBW.
- C. ELBW.
- D. low birth weight at term.
Correct Answer: B
Rationale: The correct answer is B: VLBW (Very Low Birth Weight). This classification is based on the infant weighing less than 1500 g at birth, which applies to this scenario as the infant weighs 1200 g. VLBW infants are at higher risk for complications due to their low weight and prematurity.
A: SG (Small for Gestational Age) is incorrect because it refers to infants who are below the 10th percentile for weight at a specific gestational age, not based solely on weight.
C: ELBW (Extremely Low Birth Weight) is incorrect as it typically refers to infants weighing less than 1000 g at birth, which is lower than the infant in this scenario.
D: Low birth weight at term is incorrect as it does not accurately classify a premature infant like the one in the question.
A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?
- A. The drug keeps your infant from requiring too much sedation.
- B. Surfactant improves the ability of your infant’s lungs to exchange oxygen and carbon dioxide.
- C. Surfactant is used to reduce episodes of periodic tachycardia.
- D. Your infant needs this medication to fight a possible respiratory tract infection.
Correct Answer: B
Rationale: The correct answer is B because artificial surfactant improves the ability of the infant's lungs to exchange oxygen and carbon dioxide. Surfactant reduces surface tension in the alveoli, preventing collapse and helping with gas exchange. This explanation directly relates to the purpose of surfactant therapy in treating RDS. Choices A, C, and D are incorrect because they do not accurately describe the mechanism or purpose of surfactant therapy. Choice A is incorrect as surfactant does not affect sedation needs, choice C is incorrect as surfactant is not used to address tachycardia, and choice D is incorrect as surfactant is not used to treat respiratory tract infections.
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.
Which rationale is true regarding jaundice in newborns?
- A. Jaundice can result in a newborn when the mother and newborn have the same blood type.
- B. A mother who breastfeeds her newborn who develops jaundice may have to begin formula temporarily.
- C. Bilirubin levels will drop in newborns who have jaundice and may cause brain abnormalities.
- D. Keeping a newborn with jaundice below 98.7°F is essential in lowering bilirubin levels.
Correct Answer: B
Rationale: Step 1: Breast milk jaundice is a common cause of jaundice in newborns due to a substance in breast milk that can increase bilirubin levels.
Step 2: Switching to formula temporarily can help resolve the issue as formula-fed babies have lower incidences of jaundice.
Step 3: This is supported by medical guidelines recommending temporary cessation of breastfeeding in cases of severe jaundice.
Summary:
A: Blood type compatibility does not directly cause jaundice in newborns.
C: Bilirubin levels need to be monitored and managed in newborns with jaundice to prevent brain damage.
D: Maintaining a specific temperature is not the primary method of managing jaundice in newborns.