A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights.
An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:.

This question assesses the nurse's ability to differentiate between pathological apnea and normal physiological variations in preterm neonates. Understanding neonatal respiratory development is crucial for distinguishing between clinical distress and common, benign breathing patterns observed in the premature population.

Choice A rationale: Apnea in infants is clinically defined as a cessation of breathing lasting 20 seconds or longer, or shorter if associated with bradycardia or cyanosis. Shorter pauses are considered periodic breathing, which is distinct from true apneic episodes.

Choice B rationale: While preterm infants have immature cardiovascular regulation, brief respiratory pauses followed by rapid breathing do not directly indicate fluctuating blood pressure. These patterns are primary reflections of an underdeveloped brainstem control of the respiratory rhythm and ventilation.

Choice C rationale: Maintaining a neutral thermal environment is vital for preventing cold stress, which increases oxygen consumption. However, this periodic breathing pattern is a developmental neurological phenomenon rather than a direct metabolic or thermoregulatory compensation for thermal instability.

Choice D rationale: Periodic breathing, characterized by brief pauses followed by rapid respiration, is a common and typically benign pattern in premature infants. It is attributed to the immaturity of the respiratory center in the brain and generally resolves as the infant matures.

Choice A rationale:
Inspiratory stridor. Inspiratory stridor, a high-pitched sound heard during inhalation, is a common symptom of acute epiglottitis. It is caused by the swelling and inflammation of the epiglottis, which can partially obstruct the airway and create a stridor sound during breathing.
Choice B rationale:
Complete obstruction. Using a tongue depressor to examine the throat of a child with acute epiglottitis can potentially lead to a complete airway obstruction. The epiglottis, which is already swollen, can block the airway entirely, leading to respiratory distress and potentially a life-threatening situation.
Choice C rationale:
Sore throat. A sore throat is a common symptom of various respiratory tract infections, including acute epiglottitis. However, the use of a tongue depressor can worsen the swelling and potentially lead to complete airway obstruction, which is a more immediate concern.
Choice D rationale:
Respiratory tract infection. Acute epiglottitis itself is a severe respiratory tract infection, specifically involving the epiglottis. Using a tongue depressor might exacerbate the condition, leading to airway obstruction, but it is not the cause of the respiratory tract infection.