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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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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. "I will monitor the client's blood glucose level every 8 hours." B. "I will hang a new bag of TPN and IV tubing every 24 hours." C. "I will increase the rate of the TPN infusion to ensure the correct amount is given." D. "I will obtain the client's weight every other day."

Correct Answer is B

Explanation

A. "I will monitor the client’s blood glucose level every 8 hours": Incorrect. Blood glucose should be monitored more frequently, typically every 4-6 hours, due to the risk of hyperglycemia.

B. "I will hang a new bag of TPN and IV tubing every 24 hours": This practice reduces the risk of infection associated with TPN, which is a high-risk therapy.

C. "I will increase the rate of the TPN infusion to ensure the correct amount is given": Incorrect. The TPN infusion rate should not be adjusted without a provider's order, as it can cause hyperglycemia or fluid overload.

D. "I will obtain the client’s weight every other day": Incorrect. Daily weights are necessary to monitor fluid status and nutritional effectiveness.

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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?

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Explanation

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Explanation

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