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

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

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 {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

Lithium toxicity: The client's lithium level is significantly elevated at 2.5 mEq/L (normal range is 0.6 to 1.2 mEq/L), and symptoms such as blurred vision, increased urine output, and clonic jerking of the upper extremities are indicative of lithium toxicity2.
Seizure activity: Lithium toxicity can lead to neurological symptoms, including seizures, which require close monitoring

A. A client who has a fracture and is in balance suspension traction. B. A client who is bedridden and wears a hearing aid. C. A client who is ambulatory and receiving oxygen. D. A client who uses a wheelchair and is confused.

Correct Answer is C

Explanation

A. A client in balance suspension traction requires more time and assistance, making them a lower priority.

B. A bedridden client requires significant help and is less mobile, lowering their priority.

C. A client who is ambulatory and receiving oxygen is at risk of immediate danger if the oxygen supply poses a fire hazard. They can be evacuated quickly and independently.

D. A client in a wheelchair and confused may require more time and resources for evacuation.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed ______ and will need to be monitored for _________.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

Correct Answer is C

Explanation

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

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