A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend?
Allow opportunities for newborn massage.
Cluster the newborn's care activities.
Change the newborn's position every 2 hours.
Place elbow restraints on the newborn.
The Correct Answer is B
Choice A reason:
Allowing opportunities for newborn massage is not recommended for preterm newborns, as it can increase their oxygen consumption and energy expenditure. Massage can also cause stress responses, such as increased heart rate, blood pressure, and cortisol levels.
Choice B reason:
Clustering the newborn's care activities is the best way to help the newborn conserve energy, as it minimizes the frequency of handling and stimulation. Clustering care also allows for longer periods of uninterrupted sleep, which is essential for growth and development.
Choice C reason:
Changing the newborn's position every 2 hours is not necessary for preterm newborns, as it can disrupt their sleep and cause them to lose heat. Preterm newborns have limited ability to regulate their body temperature, and frequent position changes can expose them to cold stress.
Choice D reason:
Placing elbow restraints on the newborn is not indicated for preterm newborns, unless they have a specific condition that requires them, such as a cleft lip or palate repair. Elbow restraints can restrict the newborn's movement and cause skin irritation or injury.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Hypertonia is not a characteristic of a preterm infant, but rather of a post-term infant. Hypertonia means increased muscle tone or stiffness, which is more common in infants who are overdue. Preterm infants have poor muscle tone and less subcutaneous fat.
Choice B reason:
Long toenails are also not a characteristic of a preterm infant but of a post-term infant. Long toenails indicate that the infant has grown beyond the expected gestational age. Preterm infants have short and brittle nails.
Choice C reason:
Lanugo is a characteristic of a preterm infant. Lanugo is fine, downy hair that covers the body of the fetus. It usually disappears by the 36th week of gestation, but preterm infants may still have it at birth.
Choice D reason:
Dry skin is not a characteristic of a preterm infant but of a post-term infant. Dry skin indicates that the infant has lost moisture and subcutaneous fat due to prolonged exposure to the amniotic fluid. Preterm infants have thin and transparent skin that may be covered by vernix caseosa, a white, cheesy substance that protects the skin from the amniotic fluid.
Correct Answer is A
Explanation
Choice A reason:
This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor. This is the correct answer because caput succedaneum is a swelling of the scalp that crosses the suture line and is caused by prolonged pressure on the baby's head during delivery. It can also result from the use of vacuum extraction or forceps. Caput succedaneum is harmless and usually resolves on its own within a few days.
Choice B reason:
This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin. This is incorrect because erythema toxicum is a common rash that affects newborns, but it does not cause swelling of the scalp or cross the suture line. It appears as red blotches with small white or yellow bumps that can occur anywhere on the body. Erythema toxicum is also harmless and usually disappears within a week.
Choice C reason:
This is a cephalhematoma, which will resolve on its own in 3 to 5 days. This is incorrect because cephalhematoma is bleeding under the scalp that does not cross the suture line and is caused by ruptured blood vessels in the scalp. It can also result from the use of vacuum extraction or forceps. Cephalhematoma may take weeks or months to resolve and can increase the risk of jaundice.
Choice D reason:
This is a Mongolian spot, which is found on many newborns. This is incorrect because Mongolian spots are bluish-gray patches of skin that are present at birth and are caused by melanocytes (pigment-producing cells) that are trapped in the deeper layers of the skin. They are not related to swelling or pressure on the head and usually fade by age 5.
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