Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Abdominal circumference: The increase in abdominal circumference by 1 cm (0.4 in) since the prior assessment is concerning and may indicate a complication such as abdominal distension, which could be a sign of necrotizing enterocolitis (NEC) or other gastrointestinal issues. NEC is a serious condition that is common in preterm infants, especially those receiving enteral feedings.

B. Gestational age: Being born at 34 weeks gestation is a significant risk factor. Prematurity increases the risk for complications like respiratory distress syndrome (RDS), infections, and feeding difficulties. Preterm infants are also at risk for problems with thermoregulation, which is why the neonate is on a radiant warmer.

C. Respiratory distress: The presence of substernal retractions, nasal flaring, and an elevated respiratory rate (70/min) indicates respiratory distress. Preterm neonates, especially those born at 34 weeks, are at risk for RDS due to insufficient surfactant production, which can lead to difficulty breathing and hypoxemia.

D. UAC: The umbilical arterial catheter (UAC) is commonly used for monitoring blood pressure and obtaining blood samples in neonates. However, it carries a risk for complications such as infection, thrombosis, and injury to blood vessels. This is an invasive device that could contribute to complications.

E. Feeding method (Continuous breast milk feedings via OG tube): Although feeding via an orogastric tube is a standard method for preterm neonates, it does not pose an immediate risk factor in this case. The method of feeding itself is not a complication risk. However, complications like feeding intolerance or aspiration can arise, which would require further monitoring.

G. 5-minute Apgar score: A 5-minute Apgar score of 7 is considered an acceptable score for a neonate. Although it indicates some initial difficulty, this score does not present a significant risk factor for complications by itself. A lower score would be more concerning, but a score of 7 typically suggests the neonate is transitioning well.

A. Caffeine use B. Evening meal C. Use of electronic devices D. Exercise schedule E. Bedtime Medications

Correct Answer is ["A","C"]

Explanation

A. Caffeine is a stimulant and can interfere with sleep, especially if consumed in the afternoon or evening. It can lead to difficulty falling asleep and disrupt the sleep cycle.
B. While heavy meals close to bedtime can cause discomfort or indigestion, a light evening meal generally does not significantly interfere with sleep for most individuals.
C. The use of electronic devices, particularly before bedtime, can interfere with sleep due to the blue light emitted by screens. This light can suppress the production of melatonin, a hormone that helps regulate sleep.
D. Regular exercise generally promotes better sleep. However, vigorous exercise close to bedtime may interfere with sleep due to the increase in adrenaline, but this is not always the case.
E. The medications taken by the individual do not interfere with sleep.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a neonate in the neonatal intensive care unit. Q122 Exhibits Which findings in the client's electronic medical record (EMR) are risk factors for the client developing a complication? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client in an outpatient clinic. Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

Correct Answer is ["A","C"]

Explanation

A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?

A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?

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 _________.

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?