A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant?

Place the newborn in Trendelenburg position.

Maintain oxygen saturations between 93% to 95%.

Insert an orogastric tube for decompression of the stomach.

Remove the hood every hour for 10 min to facilitate bonding.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing the newborn in Trendelenburg position is not an appropriate nursing action, as it can cause increased intracranial pressure, decreased lung expansion, and aspiration. The nurse should position the newborn in a neutral or slightly elevated head position, with the neck slightly extended.

Choice B reason: Maintaining oxygen saturations between 93% to 95% is an appropriate nursing action, as it ensures adequate oxygen delivery to the tissues and organs, while avoiding hyperoxia or hypoxia, which can cause complications, such as retinopathy of prematurity, intraventricular hemorrhage, or necrotizing enterocolitis.

Choice C reason: Inserting an orogastric tube for decompression of the stomach is not an appropriate nursing action, as it is not indicated for oxygen hood therapy, unless the newborn has abdominal distension, vomiting, or feeding intolerance. The nurse should monitor the newborn's abdominal girth, bowel sounds, and feeding tolerance, and report any signs of gastrointestinal dysfunction.

Choice D reason: Removing the hood every hour for 10 min to facilitate bonding is not an appropriate nursing action, as it can cause fluctuations in the oxygen concentration and temperature, and increase the risk of infection. The nurse should maintain the hood in place, and encourage the parents to touch, talk, and sing to the newborn, and provide skin-to-skin contact when possible.

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Correct Answer is C

Explanation

Choice A reason: To call for an immediate magnesium sulfate level is not the immediate action that the nurse should take, as it is a diagnostic test that requires a blood sample and a laboratory analysis, which can take time and delay the treatment. The nurse should first stop the infusion and notify the provider, as the client is showing signs of magnesium sulfate toxicity, which is a life-threatening condition that can cause respiratory depression, cardiac arrest, or coma.

Choice B reason: To prepare to administer hydralazine is not the immediate action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the blood pressure and the fetal status. Hydralazine is an antihypertensive drug that lowers the blood pressure and prevents the complications of severe preeclampsia, such as eclampsia, stroke, or organ damage. However, the client's blood pressure is not very high and is not the main problem at the moment.

Choice C reason: To discontinue the magnesium sulfate infusion is the immediate action that the nurse should take, as it is the first and most important intervention that can reverse the effects of magnesium sulfate and restore the neuromuscular function and the respiratory rate. Magnesium sulfate is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, but it can also cause toxicity if the dose is too high or the infusion is too fast.

Choice D reason: To administer oxygen is not the immediate action that the nurse should take, as it is a supportive intervention that improves the oxygen delivery to the tissues and organs, but does not address the underlying cause of the respiratory depression, which is the magnesium sulfate toxicity. The nurse should administer oxygen only after stopping the infusion and assessing the oxygen saturation and the respiratory status.

A. Meconium aspiration, hypoglycemia, and dry, cracked skin B. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance C. Excessive vernix caseosa covering the skin, lethargy, and RDS D. Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat

Correct Answer is A

Explanation

Choice A reason: This statement is correct, as these are the common complications of post-term infants, who are born after 42 weeks of gestation. Meconium aspiration can occur when the fetus passes meconium in utero and inhales it into the lungs, causing respiratory distress, inflammation, and infection. Hypoglycemia can occur due to the depletion of glycogen stores and the increased metabolic demands. Dry, cracked skin can occur due to the loss of vernix caseosa and the reduced amniotic fluid.

Choice B reason: This statement is incorrect, as these are the signs of neonatal hypocalcemia, which is a low level of calcium in the blood. Neonatal hypocalcemia can occur due to maternal diabetes, prematurity, or asphyxia, and can cause jitteriness, seizures, or tetany.

Choice C reason: This statement is incorrect, as these are the characteristics of preterm infants, who are born before 37 weeks of gestation. Excessive vernix caseosa covering the skin is a protective coating that prevents heat and water loss. Lethargy and RDS are signs of immaturity and underdevelopment of the central nervous system and the lungs.

Choice D reason: This statement is incorrect, as these are the features of infants with erythroblastosis fetalis, which is a hemolytic disease caused by the incompatibility of the Rh factor or the ABO blood group between the mother and the fetus. Golden yellow to green-stained skin and nails are due to the accumulation of bilirubin, which is a breakdown product of red blood cells. Absence of scalp hair and an increased amount of subcutaneous fat are due to the chronic hypoxia and edema.

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A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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