A nurse is obtaining care for a clieture 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.
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
Explanation
A. Place a warm, moist compress on the site: This helps reduce the inflammation associated with phlebitis by promoting blood flow to the affected area and easing discomfort.
B. Insert a new IV catheter distal to the discontinued IV site: Incorrect. The site with phlebitis should not be used for a new IV insertion. A new, unaffected site should be chosen.
C. Apply a pressure dressing at the IV site: Incorrect. A pressure dressing is not required for phlebitis unless there is active bleeding.
D. Express drainage from the IV site and send it to be cultured: Incorrect. Expressing drainage is not a standard practice for phlebitis unless there is an indication of infection and purulent drainage.
Correct Answer is ["B","C","D","F","G","H"]
Explanation
Frequent episodes of apnea, responds to tactile stimuli: Apnea in a neonate, especially one born preterm (at 34 weeks gestation), is not uncommon but should be carefully monitored. However, frequent apnea episodes may indicate an underlying respiratory issue, such as respiratory distress syndrome (RDS) or an infection. Apnea that requires tactile stimuli to resolve should be followed up with further assessment and possibly intervention.
Substernal retractions and nasal flaring: These are signs of respiratory distress. Substernal retractions and nasal flaring indicate the neonate is working harder to breathe, which may point to respiratory distress syndrome (RDS) or other respiratory compromise. Close monitoring and follow-up are necessary to assess the neonate's respiratory status and oxygenation.
Respiratory rate of 70/min: This is on the higher end for a neonate and may indicate respiratory distress or compensation for oxygenation issues. Close monitoring is required.
Temperature of 36.3 °C (97.3 °F): While this temperature is within the normal range for a neonate, it is on the lower end of the spectrum. Neonates, especially preterm ones, are at risk for hypothermia. The neonate is on a radiant warmer, which suggests that there may still be concerns regarding temperature regulation. This needs to be monitored closely to ensure proper thermal regulation.
Increased abdominal circumference by 1 cm (0.4 in): An increase in abdominal circumference can be a sign of feeding intolerance, such as necrotizing enterocolitis (NEC), or other gastrointestinal issues. It is important to continue monitoring for other signs of NEC or abdominal distension, which can indicate the need for intervention.
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