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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F","G"]
Explanation
Choice A:
Temperature is not a finding that the nurse should report to the provider. The normal range for temperature in newborns is 36.5 to 37 degrees Celsius axillary. The question does not provide the temperature of the newborn, but it does not indicate any signs of hypothermia or hyperthermia.
Choice B:
Respiratory findings are findings that the nurse should report to the provider. The newborn has mild grunting, nasal flaring, and intermittent retractions, which are signs of respiratory distress. These could indicate a problem with lung development, infection, or congenital heart disease.
Choice C:
Serum glucose is a finding that the nurse should report to the provider. The normal range for blood glucose in newborns is above 40 mg/dL. The question does not provide the serum glucose level of the newborn, but it could be low due to factors such as prematurity, maternal diabetes, or sepsis.
Choice D:
Hematocrit is a finding that the nurse should report to the provider. The normal range for hematocrit in newborns is 42% to 65%. The question does not provide the hematocrit level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice E:
White blood cell count is not a finding that the nurse should report to the provider. The normal range for white blood cell count in newborns is 9,000 to 30,000/mm3. The question does not provide the white blood cell count of the newborn, but it does not indicate any signs of infection or inflammation.
Choice F:
Hemoglobin is a finding that the nurse should report to the provider. The normal range for hemoglobin in newborns is 14 to 24 g/dL. The question does not provide the hemoglobin level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice G:
Heart rate is a finding that the nurse should report to the provider. The normal range for heart rate in newborns is 85 to 190 beats per minute when awake. The question does not provide the heart rate of the newborn, but it could be high due to stress, pain, fever, or hypoxia, or low due to bradycardia or cardiac arrest.
Correct Answer is A
Explanation
Choice A reason:
Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.
Choice B reason:
Administering phytonadione IM is not the nurse's priority because it is not an immediate life-saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.
Choice C reason:
Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.
Choice D reason:
Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today