A nurse is assessing a pre-term newborn who has retinopathy of prematurity (ROP).

Which of the following manifestations should the nurse expect to observe?

Leukocoria (white pupils)

Strabismus (crossed eyes)

Nystagmus (involuntary eye movements)

All of the above

Answer and Explanation

The Correct Answer is A

Leukocoria (white pupils) is a symptom of retinopathy of prematurity (ROP), an eye disease that can happen in premature babies. ROP happens when abnormal blood vessels grow on the retina, the light-sensitive layer of tissue in the back of the eye.

Choice B is wrong because strabismus (crossed eyes) is not a symptom of ROP, but a possible complication that can occur later in life.

Choice C is wrong because nystagmus (involuntary eye movements) is not a symptom of ROP, but another possible complication that can occur later in life.

Choice D is wrong because it includes choices B and C, which are incorrect.

Normal ranges for gestational age and birth weight are 38 to 42 weeks and 5.5 to 10 pounds, respectively. Babies born before 31 weeks or weighing less than 3 pounds are at risk for ROP.

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Correct Answer is A

Explanation

History of urinary tract infections.According to the Mayo Clinic, untreated vaginal infections, such as urinary tract infections or sexually transmitted infections, are risk factors for preterm labor.

These infections can cause inflammation and irritation of the cervix, which can trigger contractions and cervical dilation.

Choice B is wrong because maternal age of 25 years is not a risk factor for preterm labor.In fact, women younger than 18 or older than 35 are more likely to have a preterm delivery.

Choice C is wrong because singleton pregnancy is not a risk factor for preterm labor.On the contrary, being pregnant with twins, triplets, or more (called "multiple gestations") is associated with a higher risk of preterm labor and birth.

Choice D is wrong because cervical length of 3 cm is not a risk factor for preterm labor.A short cervix (less than 2.5 cm) or a cervix that shortens in the second trimester instead of the third trimester is a risk factor for preterm delivery.A normal cervical length ranges from 3 to 5 cm during pregnancy.

A. Administer magnesium sulfate intravenously B. Prepare for an emergency cesarean section C. Place the client in Trendelenburg position D. Administer antibiotics prophylactically

Correct Answer is B

Explanation

Prepare for an emergency cesarean section.This is because the client has pre-term labor that has not responded to tocolytic therapy, which are drugs that are used to delay delivery for a short time.The client’s cervix is dilated to 4 cm and she is experiencing regular contractions every 3 minutes, which are signs of active labor.The baby is at 33 weeks of gestation, which is premature and may have complications such as respiratory distress syndrome or bleeding in the brain.

Therefore, the client needs an emergency cesarean section to deliver the baby as soon as possible and prevent further risks.

Choice A is wrong because administering magnesium sulfate intravenously is a type of tocolytic therapy that the client has already failed.Magnesium sulfate may also have side effects such as nausea, vomiting, flushing, headache, and muscle weakness.

Choice C is wrong because placing the client in Trendelenburg position, which is lying on the back with the feet elevated above the head, is not recommended for preterm labor.This position may increase the risk of aspiration, decrease cardiac output, and impair gas exchange.

Choice D is wrong because administering antibiotics prophylactically is not indicated for preterm labor unless there is evidence of infection in the uterus or membranes.

Antibiotics may also cause allergic reactions or bacterial resistance

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A nurse is assessing a pre-term newborn who has retinopathy of prematurity (ROP). Which of the following manifestations should the nurse expect to observe?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who is at 34 weeks of gestation and has pre-term labor. Which of the following findings is a risk factor for pre-term labor?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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A nurse is assessing a pre-term newborn who has retinopathy of prematurity (ROP).

Which of the following manifestations should the nurse expect to observe?