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 B

Explanation

Choice A reason: Polyuria is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, diabetes, or renal impairment. A client with severe preeclampsia may have oliguria, which is a urine output of less than 500 mL in 24 hours, due to the decreased renal perfusion and function.

Choice B reason: Report of headache is an expected finding in a client with severe preeclampsia, as it can indicate increased intracranial pressure, cerebral edema, or vasospasm. A client with severe preeclampsia may also have other neurological symptoms, such as blurred vision, scotoma, photophobia, or hyperreflexia.

Choice C reason: Tachycardia is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, infection, anxiety, or fetal distress. A client with severe preeclampsia may have bradycardia, which is a heart rate of less than 60 beats per minute, due to the increased vagal tone and blood pressure.

Choice D reason: Absence of clonus is not an expected finding in a client with severe preeclampsia, as it can indicate normal or decreased neuromuscular irritability. A client with severe preeclampsia may have positive clonus, which is a rhythmic jerking of the foot when the ankle is dorsiflexed, due to the increased reflex excitability and hyperactivity.

A. Erythroblastosis fetalis B. Hypobilirubinemia C. Biliary atresia D. Transient clotting difficulties

Correct Answer is A

Explanation

Choice A reason: Erythroblastosis fetalis is the correct answer, as it is a hemolytic disease of the newborn that occurs when the mother is Rh-negative and the newborn is Rh-positive, and the maternal antibodies cross the placenta and destroy the newborn's red blood cells, causing anemia, jaundice, and edema. Rh0 (D) immunoglobulin is an injection that prevents the formation of Rh-positive antibodies in the mother, and reduces the risk of erythroblastosis fetalis in the current or subsequent pregnancies.

Choice B reason: Hypobilirubinemia is not the correct answer, as it is a low level of bilirubin in the blood that can cause pale skin, poor feeding, or lethargy. Hypobilirubinemia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a common or serious complication in the newborn.

Choice C reason: Biliary atresia is not the correct answer, as it is a congenital defect of the bile ducts that prevents the flow of bile from the liver to the intestine, causing jaundice, dark urine, and clay-colored stools. Biliary atresia is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is not a preventable complication in the newborn.

Choice D reason: Transient clotting difficulties is not the correct answer, as it is a bleeding disorder that occurs due to the deficiency of vitamin K, which is essential for the synthesis of clotting factors. Transient clotting difficulties is not related to the Rh factor or the Rh0 (D) immunoglobulin injection, and it is preventable by administering vitamin K to the newborn.

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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?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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