A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply.
Provide early feedings to prevent hypoglycemia
Maintain oxygen saturation parameters
Obtain hemoglobin and hematocrit laboratory tests
Monitor urinary output
Insert a peripheral IV
Correct Answer : A,B,C,D,E
A. Providing early feedings can help prevent hypoglycemia, a common complication of polycythemia.
B. Maintaining oxygen saturation parameters, which can indicate the adequacy of tissue oxygenation and perfusion.
C. Obtaining hemoglobin and hematocrit laboratory tests is essential for diagnosing and monitoring polycythemia.
D. Polycythemic neonates may have decreased urinary output due to reduced renal blood flow, dehydration, or increased risk of thrombosis. The nurse should monitor the urinary output and report any signs of oliguria, anuria, hematuria, or renal failure.
E. A peripheral IV is a catheter inserted into a vein to administer fluids, medications, or blood products. Polycythemic neonates may require a partial exchange transfusion, which is a procedure where some of the neonate's blood is removed and replaced with normal saline or donor blood. This can help lower the hematocrit and viscosity and improve oxygen delivery and tissue perfusion. The nurse should insert a peripheral IV and prepare for the transfusion as ordered by the physician.
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Related Questions
Correct Answer is D
Explanation
A. While acknowledging the father's concerns is important, this response doesn't provide guidance on addressing potential depression in the son.
B. Offering to refer the son for evaluation with a therapist if mood issues are noticed is important and provides proactive support and guidance for addressing potential depression but screening children with a risk factor for depression from the age of 11 is the best choice.
C. While regular screening may be indicated for at-risk teens, waiting until age 14 may miss opportunities for early intervention in some cases.
D. Screening for depression is recommended for all children aged 11 and older, especially those who have a family history of depression or other risk factors. The nurse should inform the father that screening his son for depression is important and can help identify any signs or symptoms early. This is based on the recommendations of the American Academy of Pediatrics, which state that pediatric primary care providers should screen all children and adolescents for depression at least once a year, starting from age 11.
Correct Answer is ["C","D","E"]
Explanation
A. Providing praise when deserved is important for reinforcing positive behavior and fostering self-esteem.
B. Speaking to the child as an authority figure may create distance and hinder effective communication.
C. Talking face to face and being aware of body language can enhance communication and understanding between parents and adolescents.
D. Acknowledging uncertainty and not pretending to have all the answers can foster honesty and openness in communication.
E. Asking questions to understand the adolescent's perspective and feelings encourages dialogue and mutual understanding.
F. Admitting mistakes and modeling accountability is important for building trust and demonstrating humility in parent-adolescent relationships.
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