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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Incorrect. Assessing medication use is a nursing responsibility and cannot be delegated to an AP.

B. Determine if the AP has the skills to perform the test: The nurse must ensure that the AP is competent to perform the task safely and accurately before delegation, as part of the nurse's responsibility in delegation.

C. Help the AP perform the blood glucose test: Incorrect. The task should be performed independently by the AP if delegated.

D. Have the AP check the medical record for prior blood glucose test results: Incorrect. Reviewing the medical record is a nursing responsibility and not typically delegated to an AP.

A. Draw blood specimens for culture and sensitivity. B. Administer nitroglycerin 0.4 mg SL 30 min before the procedure. C. Obtain a CBC with differential. D. Transport the client to radiology for a CT scan.

Correct Answer is C

Explanation

A. Draw blood specimens for culture and sensitivity: Incorrect. Blood cultures are not routinely required for cardiac catheterization.

B. Administer nitroglycerin 0.4 mg SL 30 min before the procedure: Incorrect. Nitroglycerin is not typically administered before a cardiac catheterization unless specifically ordered.

C. Obtain a CBC with differential: A complete blood count (CBC) is necessary before a cardiac catheterization to assess for potential bleeding risks, infection, or anemia.

D. Transport the client to radiology for a CT scan: Incorrect. Cardiac catheterization is performed in a specialized cardiac catheterization lab, not in radiology.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to delegate the fasting blood glucose testing for a client who has diabetes mellitus to an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing a client to undergo a cardiac catheterization. Which of the following tasks should the nurse perform prior to the procedure?

Correct Answer is C

Explanation

A nurse is caring for a client who is in active labor. The nurse should notify the provider for which of the following findings?

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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

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