Institute contact precautions.This is because the infant may havenecrotizing enterocolitis (NEC), which is the most common cause of bloody stool in preterm infants.

NEC is a serious condition that involves inflammation and necrosis of the intestinal wall and can lead to perforation, sepsis, and death.NEC is also a potential source of infection for other infants in the NICU, so contact precautions are necessary to prevent cross-contamination.

Choice A is wrong because obtaining a rectal temperature is not indicated for an infant with bloody stool.Rectal temperature can cause irritation and bleeding of the rectal mucosa and can also increase the risk of perforation if there is intestinal necrosis.

Choice C is wrong because decreasing the amount of the feeding is not enough to manage an infant with bloody stool.

The infant may need to have the feeding stopped completely and receive parenteral nutrition until the bowel heals.Decreasing the feeding may also compromise the infant’s growth and development.

Choice D is wrong because assessing for abdominal distention is not a nursing action but a nursing assessment.

Abdominal distention is a common sign of feeding intolerance and NEC, but it is not specific or sensitive enough to diagnose the condition.Other signs and symptoms of NEC include bile-stained or bloody gastric residuals, emesis, diarrhea, temperature instability, apnea, bradycardia, hypotension, and lethargy.

Absent Moro reflex on the affected side indicates a possible injury to the brachial plexus, which is the nerve network that controls the movements and sensations of the shoulder, arm, hand and fingers.Shoulder dystocia can cause brachial plexus injuries when the baby’s shoulder gets stuck behind the mother’s pubic bone during delivery.

Choice B is wrong because flaccid paralysis of both lower extremities is not a common complication of shoulder dystocia.

It could be a sign of spinal cord injury or other neurological disorders.

Choice C is wrong because facial asymmetry when crying or smiling is a sign of facial nerve palsy, which can occur due to compression of the facial nerve during delivery.

It is not specific to shoulder dystocia.

Choice D is wrong because inability to suck or swallow is not a typical sign of shoulder dystocia.

It could be caused by other factors such as prematurity, neurological problems, or congenital anomalies.

Normal ranges for Moro reflex are present at birth and disappear by 4 to 6 months of age.

Normal ranges for facial nerve function are symmetrical movements of both sides of the face.

Normal ranges for sucking and swallowing are coordinated and effective feeding within the first hour after birth.

Discontinue the oxytocin (Pitocin) infusion.This is because the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction indicate alate deceleration, which is a sign offetal hypoxia.Oxytocin is a drug that stimulates uterine contractions and can causeuterine hyperstimulation, which reduces blood flow to the placenta and the fetus.By stopping the oxytocin infusion, the nurse can reduce the frequency and intensity of contractions and improve fetal oxygenation.

Choice A is wrong because administering oxygen via facemask may not be enough to reverse fetal hypoxia if oxytocin is still being infused.Choice B is wrong because placing the client on her left side may improve maternal blood flow to the placenta, but it will not reduce the effects of oxytocin on uterine activity.

Choice D is wrong because notifying the healthcare provider is not the most urgent action at this time.The nurse should first discontinue the oxytocin infusion and then notify the healthcare provider.

Normal ranges for FHR are 110 to 160 beats per minute, with a baseline variability of 6 to 25 beats per minute.

Normal ranges for uterine contractions are 2 to 5 contractions in 10 minutes, lasting

This is because the infant born through meconium-stained amniotic fluid (MSAF) may have meconium aspiration syndrome (MAS), which is a condition that causes respiratory distress due to the inhalation of meconium into the lungs.The priority action for the nurse is to evaluate the infant’s breathing and circulation and initiate resuscitation if needed.

Choice A is wrong because suctioning the infant’s mouth and nose with a bulb syringe is not recommended unless the infant has obvious meconium in the airway and is not vigorous.Suctioning may cause bradycardia, hypoxia, or airway trauma.

Choice C is wrong because drying and stimulating the infant with a warm towel is part of the initial steps of resuscitation, but it should be done after assessing the infant’s heart rate and respiratory effort.Drying and stimulating may also increase the risk of meconium aspiration if the infant gasps.

Choice D is wrong because clamping and cutting the umbilical cord is not a priority action for an infant with possible MAS.The cord should be clamped and cut after ensuring that the infant is stable and has adequate oxygenation.

Loose, peeling skin without lanugo or vernix is a symptom of post-term infants who have intrauterine growth restriction (IUGR).Post-term infants are born after 42 weeks of gestation and may have reduced placental function, resulting in less nutrition and oxygen for the fetus.This can cause them to have low birth weight, decreased subcutaneous fat and muscle mass, and dry skin.

Choice A is wrong because a large head in proportion to body size is not a sign of IUGR.It may indicate a congenital anomaly or a chromosomal disorder.

Choice C is wrong because increased subcutaneous fat and muscle mass are not signs of IUGR.They are signs of normal fetal growth and development.

Choice D is wrong because hypertonia and hyperreflexia are not signs of IUGR.They may indicate a neurological problem or a perinatal asphyxia (lack of oxygen during birth).

This is because hypoglycemia in newborns can cause seizures, brain damage, and developmental delays, and frequent monitoring can help detect and correct low blood glucose levels promptly.

Some additional information about the other choices are:

Choice B. Administer glucagon subcutaneously as prescribed.This is wrong because glucagon is used to treat hypoglycemia caused by hyperinsulinism, which is a rare condition in newborns.Most cases of hypoglycemia in term infants are due to transient factors such as delayed feeding, maternal diabetes, or perinatal stress.

Choice C. Discontinue IV dextrose when blood glucose reaches 60 mg/dL.This is wrong because 60 mg/dL is still below the normal range of blood glucose for newborns, which is 70 to 100 mg/dL.Discontinuing IV dextrose too early can cause rebound hypoglycemia and increase the risk of neurologic complications.

Choice D. Feed breast milk or formula every four hours.This is wrong because feeding every four hours may not be enough to maintain adequate blood glucose levels in newborns with hypoglycemia.Infants with hypoglycemia should be fed more frequently, such as every two to three hours, or on demand.Breast milk or formula can also be supplemented with IV dextrose if needed.

Increased oxygen saturation.This indicates that the condition is improving because it means that the blood is getting more oxygen in the lungs and less blood is shunting from the aorta to the pulmonary artery through the patent ductus arteriosus (PDA).

Choice A is wrong because decreased heart rate can be a sign of hypoxia, acidosis, or heart failure, which are complications of PDA.

Choice B is wrong because increased blood pressure can be a sign of increased systemic vascular resistance, which can result from decreased tissue perfusion due to PDA.

Choice C is wrong because decreased respiratory rate can be a sign of respiratory depression, which can be caused by some medications used to treat PDA, such as indomethacin or ibuprofen.

Normal ranges for oxygen saturation in preterm infants are between 88% and 95%.

Normal ranges for heart rate in preterm infants are between 120 and 160 beats per minute.

Normal ranges for blood pressure in preterm infants depend on gestational age and weight.

Normal ranges for respiratory rate in preterm infants are between 40 and 60 breaths per minute.

Phototherapy is a treatment that uses light to break down bilirubin in the blood and make it easier for the liver to eliminate it.

Phototherapy is effective when:

• The bilirubin levels decrease within 24 hours of treatment.

This means that the bilirubin is being cleared faster than it is being produced.

• The urine output and stool frequency increase during treatment.

This means that the bilirubin is being excreted through the kidneys and intestines.

• The skin color and muscle tone improve after treatment.

This means that the bilirubin is no longer causing jaundice or affecting the nervous system.

Statement A is wrong because it only describes one aspect of phototherapy effectiveness.

Statement B is wrong because it only describes another aspect of phototherapy effectiveness.

Statement C is wrong because it only describes the outcome of phototherapy effectiveness.

Statement D is correct because it includes all three aspects of phototherapy effectiveness.

Reticulocyte count 2%.

A reticulocyte count measures the percentage of immature red blood cells (RBCs) in the blood.A low reticulocyte count indicates that the bone marrow is not producing enough RBCs, which is a characteristic feature of anemia of prematurity (AOP).A normal reticulocyte count for preterm infants is 3-6%.

Choice A is wrong because hemoglobin 10 g/dL is within the normal range for preterm infants.

Hemoglobin is the protein in RBCs that carries oxygen.

A low hemoglobin level indicates anemia.

Choice B is wrong because hematocrit 30% is within the normal range for preterm infants.

Hematocrit is the percentage of blood volume that is occupied by RBCs.

A low hematocrit level indicates anemia.

Choice D is wrong because platelet count 150,000/mm3 is within the normal range for preterm infants.

Platelets are cell fragments that help with blood clotting.

A low platelet count indicates thrombocytopenia, which is a different condition from anemia.

Exchange transfusion (ET) is a procedure that involves removing the infant’s blood and replacing it with compatible donor blood to reduce the level of bilirubin and/or antibody-coated red blood cells.It is a high-risk intervention that can cause serious complications such as vascular accidents, cardiovascular compromise, and electrolyte and hematologic derangement.

Therefore, it is essential to obtain informed consent from the parent before performing ET.

Choice B is wrong because checking the newborn’s blood type and crossmatch is not the first action the nurse should take.

Although it is important to ensure compatibility between the donor and recipient blood, it is not as urgent as obtaining informed consent.

Choice C is wrong because inserting two umbilical catheters for blood withdrawal and infusion is not the first action the nurse should take.

Although it is necessary to establish vascular access for ET, it is not as crucial as obtaining informed consent.

Choice D is wrong because monitoring the newborn’s vital signs and oxygen saturation is not the first action the nurse should take.

Although it is vital to assess the newborn’s condition before, during, and after ET, it is not as imperative as obtaining informed consent.

Normal ranges for bilirubin levels vary depending on the gestational age and postnatal age of the newborn.The American Academy of Pediatrics (AAP) has published nomograms for initiating phototherapy and ET based on these factors.According to the AAP, ET should be considered when the bilirubin level exceeds 25 mg/dL (428 μmol/L) in term infants or 20 mg/dL (342 μmol/L) in preterm infants with risk factors for neurotoxicity.