A nurse is planning care for a pre-term newborn who has a diagnosis of intraventricular hemorrhage (IVH).
Which of the following interventions should the nurse include in the plan?
Monitor vital signs and neurological status frequently
Administer antibiotics as prescribed
Elevate the head of the bed to 30 degrees
Provide supplemental oxygen as needed
The Correct Answer is A
Monitor vital signs and neurological status frequently.
This is because intraventricular hemorrhage (IVH) is a common and serious complication of prematurity that can lead to hydrocephalus, cerebral palsy, and developmental delays. Monitoring vital signs and neurological status can help detect changes in intracranial pressure, bleeding, and infection.
Choice B is wrong because antibiotics are not indicated for IVH unless there is evidence of infection.
Choice C is wrong because elevating the head of the bed to 30 degrees can increase the risk of IVH by reducing cerebral perfusion pressure and causing venous congestion.
Choice D is wrong because supplemental oxygen is not recommended for IVH unless there is hypoxia or respiratory distress. Excessive oxygen can cause oxidative stress and vasoconstriction, which can worsen IVH.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Assess fetal heart rate using a Doppler device.
This is because low back pain and pelvic pressure at 36 weeks of gestation may indicate preterm labor, which can affect the fetal well-being.Therefore, the nurse should assess the fetal heart rate as a priority to determine if the fetus is in distress or not.
Choice A is wrong because tocolytic medication is used to stop uterine contractions, not to relieve low back pain and pelvic pressure.Choice B is wrong because resting in a side-lying position may help with blood circulation and reduce supine hypotensive syndrome, but it does not address the possible cause of low back pain and pelvic pressure.Choice D is wrong because assessing vaginal discharge for any change may indicate infection, rupture of membranes, or cervical dilation, but it is not as urgent as assessing fetal heart rate.
Some interventions for preventing and treating low back pain and pelvic pressure during pregnancy include exercise, water-based exercise, acupuncture, osteomanipulative therapy, craniosacral therapy, and pelvic support belts.
However, these interventions should be discussed with the health care provider before starting them.
Correct Answer is D
Explanation
According to the search results, magnesium sulfate can have a negative effect on the fetal heart rate (FHR) by lowering the baseline, decreasing the variability, and reducing the reactivity or acceleration pattern.Absent variability means that there is no fluctuation in the FHR and it indicates fetal hypoxia or acidosis.
This is a potential adverse effect of magnesium sulfate on the fetus and requires immediate intervention.
Choice A.Accelerations is wrong because accelerations are transient increases in the FHR that indicate fetal well-being.They are not affected by magnesium sulfate.
Choice B.Early decelerations is wrong because early decelerations are decreases in the FHR that occur with uterine contractions and are caused by fetal head compression.They are benign and do not indicate fetal distress.They are not associated with magnesium sulfate.
Choice C.Variable decelerations is wrong because variable decelerations are abrupt decreases in the FHR that vary in shape, duration, and timing and are caused by umbilical cord compression.
They may or may not indicate fetal compromise.
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