A nurse is obtaining a culture of a newborn. Which of the following sites should the nurse use?
Keep the client on NPO status.
Administer a laxative to the client.
Apply heat to the client's abdomen.
Place the client's head of bed flat.
None
None
The Correct Answer is D
A. Keeping a newborn on NPO (nothing by mouth) status may be required in specific situations but not generally for routine care.
B. Laxatives are not routinely administered to newborns unless medically indicated for constipation.
C. Applying heat to the abdomen is not appropriate unless ordered by a healthcare provider, especially if the infant's temperature regulation is compromised.
D. Placing the head of the bed flat can help with positioning the newborn to prevent any breathing difficulties or aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.
Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.
Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.
Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.
Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Bowel perforation is a serious complication that can occur as a result of necrotizing enterocolitis (NEC), which is a condition often seen in preterm infants. In NEC, the intestines become inflamed and can eventually rupture, leading to bowel perforation. The neonate's symptoms, including abdominal distention, firm abdomen, decreased bowel sounds, and a small amount of blood in the stool, are consistent with NEC. The abdominal x-ray showing marked distention of the intestine further supports this diagnosis.
Necrotizing enterocolitis (NEC) is a common and life-threatening condition in preterm infants (like this neonate born at 34 weeks gestation), particularly those receiving enteral feedings. It can lead to bowel perforation, sepsis, and other serious complications.
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