A nurse is caring for a neonate in the neonatal intensive care unit.
The nurse is reviewing the neonate's electronic medical record.
Drag words from the choices below to fill in each blank in the following sentence.
Following discontinuation of feedings, the nurse should monitor for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Sepsis: Preterm neonates are at increased risk for infections, including sepsis. Discontinuation of feedings, along with the other signs observed (such as abdominal distention, blood in stool, lethargy, and hypotonia), may suggest the onset of infection, which requires close monitoring.
Hypotension: Preterm neonates are also at risk for hypotension due to immature circulatory systems. The stress of gastrointestinal disturbances, such as abdominal distention and the potential for necrotizing enterocolitis (NEC), can result in decreased perfusion, contributing to hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Belching: A common, benign post-procedure occurrence.
B. Sore throat: Expected due to endoscope insertion.
C. Flatulence: Typically benign and not concerning post-EGD.
D. Abdominal pain: May indicate a perforation or other serious complication and requires immediate evaluation.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
|
Potential action |
Indicated |
Contraindicated |
|
Ask the client about the content of their hallucinations. |
✓ |
|
|
Instruct the client on expected hygiene practices. |
✓ |
|
|
Allow the client to watch TV at a high volume. |
✓ |
|
|
Assess the client for suicidal ideation. |
✓ |
|
|
Place the client in a room near the activity |
✓ |
Rationale
- Ask the client about the content of their hallucinations: Indicated
- Understanding the content of hallucinations can help in assessing the severity and nature of the client's condition, and in planning appropriate interventions.
- Instruct the client on expected hygiene practices: Indicated
- Encouraging and educating the client about personal hygiene is important for their overall well-being and social interactions.
- Allow the client to watch TV at a high volume: Contraindicated
- High volume and excessive stimulation can exacerbate symptoms of schizophrenia, such as hallucinations and agitation.
- Assess the client for suicidal ideation: Indicated
- Regular assessment for suicidal thoughts is crucial, even if the client initially denies them, as their mental state can change.
- Place the client in a room near the activity: Contraindicated
- A quieter environment is generally more beneficial for clients with schizophrenia to reduce overstimulation and stress.
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