A nurse is planning care for a preterm newborn.
Which of the following nursing interventions to promote development should be included in the plan of care?
Keep the newborn in a well-lit nursery.
Cluster the newborn's care activities.
Use fingertips when calming the newborn.
Position the newborn to promote extension of muscles.
The Correct Answer is B
Choice A rationale
Keeping the newborn in a well-lit nursery may interfere with their ability to develop circadian rhythms, which are critical for growth and development. Premature newborns are particularly sensitive to environmental stress, and excessive lighting can disrupt their sleep-wake cycle, increasing stress and affecting neurological development.
Choice B rationale
Clustering care activities minimizes disruptions and allows the newborn to have longer periods of rest. This approach is vital for preterm infants, as uninterrupted sleep enhances brain growth, reduces energy expenditure, and promotes physiological stability, such as maintaining appropriate heart and respiratory rates.
Choice C rationale
Using fingertips when calming the newborn may not provide the soothing effects of a whole-hand approach. Gentle hand placement offers a more consistent pressure that mimics the containment provided in the womb, aiding in neuromuscular development and decreasing stress in preterm infants.
Choice D rationale
Positioning the newborn to promote muscle extension opposes the fetal position they naturally adopt and disrupts their physiological flexion posture. This posture facilitates stability and self-regulation and supports motor development, which is essential for preterm infants adjusting to life outside the womb.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A history of breast cancer is a contraindication for menopausal hormone therapy (HT) due to its potential to stimulate hormone receptor-positive cancer cells. Estrogen, a component of HT, may promote the growth of residual malignant cells. HT must be avoided to minimize the recurrence risk. Regular screening and alternative symptom management are recommended for these patients.
Choice B rationale
GERD management with proton pump inhibitors or H2 receptor antagonists does not contraindicate HT. These conditions are unrelated to hormone therapy risks or benefits. HT may even aid in esophageal mucosal protection in some menopausal women, but only under clinical evaluation.
Choice C rationale
Dermatitis, being a localized skin condition, has no direct correlation to HT contraindications. While some patients may report worsened symptoms with HT, it is not a standard exclusion criterion. Hormone therapy decisions should focus on systemic and oncological considerations rather than minor dermatologic history.
Choice D rationale
COPD, while a chronic respiratory condition, is not a standard contraindication for HT. Careful evaluation of cardiopulmonary status is necessary before initiating HT, as estrogen may influence thromboembolic risk, particularly in sedentary individuals, but it is not specifically contraindicated in COPD cases.
Correct Answer is A
Explanation
Choice A rationale
Pain is a hallmark symptom of sickle cell crisis due to vaso-occlusion, which restricts blood flow and oxygen delivery to tissues. It results from ischemia in affected areas, triggering severe discomfort that requires prompt management with analgesics and interventions to improve circulation.
Choice B rationale
Constipation is not typically associated with sickle cell crisis. While dehydration might contribute to gastrointestinal changes, the primary symptoms revolve around pain and vaso-occlusive events impacting blood flow and oxygen delivery.
Choice C rationale
High fever can occur due to infections secondary to spleen dysfunction in sickle cell patients, but it is not a direct symptom of crisis itself. Fever requires evaluation to rule out underlying causes, as infections pose serious risks for these individuals.
Choice D rationale
Bradycardia is atypical in sickle cell crisis. Instead, tachycardia may occur due to compensatory mechanisms for ischemia and hypoxia. Bradycardia is unrelated to the vaso-occlusive events characteristic of sickle cell crises. .
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