A nurse is caring for a neonate in the neonatal intensive care unit.
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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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
Correct Answer is C
Explanation
A. Tympanic thermometers are not recommended for newborns because the ear canal is difficult to assess accurately in this age group.
B. Oral temperatures are not recommended for newborns due to the difficulty in ensuring accuracy.
C. The axillary site is the recommended method for obtaining a newborn's temperature. It is safe and non-invasive.
D. Rectal temperatures are accurate but are invasive and may cause discomfort or injury. It should only be used if other methods are not feasible.
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