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A nurse is caring for a neonate in the neonatal intensive care unit.

Exhibits

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Nurses' Notes

1200:

The neonate is 3 days old. Lung sounds clear to auscultation. Frequent episodes of apnea, responds to tactile stimuli. Oxygen saturation 95% to 98% via nasal cannula. Neonate on radiant warmer.

Temperature 36.3° C (97.3° F)

Heart rate 158/min

Respiratory rate 70/min

Substernal retractions and nasal flaring noted. Orogastric (OG) tube placement verified. Continuous breast milk feedings via OG tube initiated 12 hr ago. The umbilical arterial catheter (UAC) site is clean, dry, and intact. Peripheral pulses 2+. Capillary refill brisk. Abdomen is soft, bowel sounds are present. Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment.

Lung sounds clear to auscultation

Frequent episodes of apnea

responds to tactile stimuli

Temperature 36.3° C (97.3° F)

Heart rate 158/min

Respiratory rate 70/min

Substernal retractions and nasal flaring noted

Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment

Answer and Explanation

The Correct Answer is ["B","C","D","F","G","H"]

Frequent episodes of apnea, responds to tactile stimuli: Apnea in a neonate, especially one born preterm (at 34 weeks gestation), is not uncommon but should be carefully monitored. However, frequent apnea episodes may indicate an underlying respiratory issue, such as respiratory distress syndrome (RDS) or an infection. Apnea that requires tactile stimuli to resolve should be followed up with further assessment and possibly intervention.

Substernal retractions and nasal flaring: These are signs of respiratory distress. Substernal retractions and nasal flaring indicate the neonate is working harder to breathe, which may point to respiratory distress syndrome (RDS) or other respiratory compromise. Close monitoring and follow-up are necessary to assess the neonate's respiratory status and oxygenation.

Respiratory rate of 70/min: This is on the higher end for a neonate and may indicate respiratory distress or compensation for oxygenation issues. Close monitoring is required.

Temperature of 36.3 °C (97.3 °F): While this temperature is within the normal range for a neonate, it is on the lower end of the spectrum. Neonates, especially preterm ones, are at risk for hypothermia. The neonate is on a radiant warmer, which suggests that there may still be concerns regarding temperature regulation. This needs to be monitored closely to ensure proper thermal regulation.

Increased abdominal circumference by 1 cm (0.4 in): An increase in abdominal circumference can be a sign of feeding intolerance, such as necrotizing enterocolitis (NEC), or other gastrointestinal issues. It is important to continue monitoring for other signs of NEC or abdominal distension, which can indicate the need for intervention.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. While medication may be helpful for sleep disturbances, offering sleep aids should not be the first response. Respite care is a more appropriate solution.

B. Although caring for someone who is terminally ill can be challenging, this response lacks empathy and does not offer practical support.

C. Respite care provides relief for caregivers by allowing them to take time off, which is appropriate for this situation.

D. While encouraging the son’s efforts is important, this response doesn't address the son's need for support or practical help with his own well-being.

A. Keep neonate prone B. Administer total parenteral nutrition (TPN) C. Encourage parent bonding D. Obtain an arterial blood gas E. Attach OG tube to low intermittent suction F. Repeat abdominal x-ray every 24 hr G. Obtain a CBC and blood culture H. Administer IV antibiotics

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"A"}}

Explanation

Intervention	Anticipated	Contraindicated
Keep neonate prone		✅
Administer total parenteral nutrition (TPN)	✅
Encourage parent bonding	✅
Obtain an arterial blood gas	✅
Attach OG tube to low intermittent suction	✅
Repeat abdominal x-ray every 24 hr		✅
Obtain a CBC and blood culture	✅
Administer IV antibiotics	✅

Rationale:

Keep neonate prone: Contraindicated. Placing the neonate in a prone position may increase the risk of aspiration, especially in the context of respiratory distress or abdominal issues, so it is generally avoided unless clinically necessary in a controlled environment.

Administer total parenteral nutrition (TPN): Anticipated. TPN may be required if the neonate is unable to tolerate oral or enteral feeding due to gastrointestinal distress, as seen with abdominal distention and blood in stool.

Encourage parent bonding: Anticipated. Parent bonding is important for the emotional and developmental support of the neonate, even in critical care settings. However, it must be done in a manner that does not compromise the neonate’s health (e.g., ensuring sterile technique).

Obtain an arterial blood gas: Anticipated. Given the neonate's respiratory status and potential infection, obtaining an ABG is appropriate to assess acid-base balance and oxygenation status.

Attach OG tube to low intermittent suction: Anticipated. Suctioning through the OG tube may be necessary if the neonate has signs of gastrointestinal distress, such as abdominal distention, to remove excess gastric contents or air.

Repeat abdominal x-ray every 24 hr: Contraindicated. Repeating an x-ray every 24 hours may not be necessary unless there are significant changes in the neonate’s condition. Continuous monitoring with clinical assessments is typically prioritized.

Obtain a CBC and blood culture: Anticipated. Given the neonate's lethargy, hypotonia, and other concerning signs, a CBC and blood cultures are necessary to evaluate for infection, which is a common complication in critically ill neonates.

Administer IV antibiotics: Anticipated. Administration of IV antibiotics is essential, especially with signs of possible infection such as lethargy, distended abdomen, and blood in the stool, which may indicate sepsis or necrotizing enterocolitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"A"}}

Explanation

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