A nurse is caring for a neonate in the neonatal intensive care unit. Q122
Which findings in the client's electronic medical record (EMR) are risk factors for the client developing a complication? Select all that apply.
Abdominal circumference
Gestational age
Respiratory distress
UAC
Feeding method
5-minute Apgar score
Correct Answer : A,B,C,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. There is no need to replace the catheter unless it is obstructed or malfunctioning.
B. Credé’s maneuver is used for bladder emptying, not for continuous bladder irrigation.
C. Pink-tinged urine is expected in the first 24 hours after a transurethral resection of the prostate (TURP). The nurse should maintain the irrigation rate to prevent clot formation.
D. Warming the irrigation solution is not indicated.
Correct Answer is ["A","B","C"]
Explanation
A. Promoting health care access is a core element of advocacy, ensuring clients receive appropriate care.
B. Encouraging clients to seek information from providers empowers them to make informed decisions.
C. Addressing client needs when providing resources ensures care is client-centered.
D. Making decisions on behalf of clients without their input is not advocacy and undermines their autonomy.
E. Honoring family requests to withhold information violates the client's right to know about their care unless legally justified.
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