A nurse is caring for a newborn.

Exhibits

SELECT words from the choices below to fill in each blank in the following sentence.

The client is at risk for developing

________

 and

___________

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.

Rationale

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.