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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "I know I am at increased risk to develop type 2 diabetes." is a correct statement, because it indicates that the client understands the long-term implications of gestational diabetes. The client should be aware that gestational diabetes increases the risk of developing type 2 diabetes later in life, and that she should have regular screening and follow-up.
Choice B reason: "I will take my glyburide daily with breakfast." is a correct statement, because it indicates that the client understands the medication regimen for gestational diabetes. The client should take glyburide, a sulfonylurea that lowers blood glucose levels, as prescribed by the provider, and monitor her blood glucose levels before and after meals.
Choice C reason: "I will reduce my exercise schedule to 3 days a week." is an incorrect statement, because it indicates that the client does not understand the importance of physical activity for gestational diabetes. The client should exercise at least 30 minutes a day, 5 days a week, unless contraindicated by the provider. Exercise can help improve insulin sensitivity, lower blood glucose levels, and prevent excessive weight gain.
Choice D reason: "I should limit my carbohydrates to 50% of caloric intake." is a correct statement, because it indicates that the client understands the dietary guidelines for gestational diabetes. The client should consume a balanced diet that provides adequate but not excessive amounts of carbohydrates, protein, and fat, and that is consistent in carbohydrate intake throughout the day.
Correct Answer is A
Explanation
Choice A reason: A client who is experiencing preterm labor at 26 weeks of gestation is a suitable candidate for tocolytic therapy, because it can help delay the delivery and allow time for fetal lung maturation and transfer to a tertiary care center. Tocolytic therapy is indicated for clients who have regular uterine contractions and cervical changes before 37 weeks of gestation.
Choice B reason: A client who is experiencing fetal death at 32 weeks of gestation is not a suitable candidate for tocolytic therapy, because it has no benefit for the mother or the fetus. Tocolytic therapy is contraindicated for clients who have fetal demise, as it can increase the risk of infection and coagulation disorders.
Choice C reason: A client who has a post-term pregnancy at 42 weeks of gestation is not a suitable candidate for tocolytic therapy, because it can harm the mother and the fetus. Tocolytic therapy is contraindicated for clients who have post-term pregnancy, as it can increase the risk of placental insufficiency, fetal distress, and meconium aspiration.
Choice D reason: A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation is not a suitable candidate for tocolytic therapy, because it is not necessary or effective. Braxton-Hicks contractions are irregular and painless contractions that do not cause cervical changes or labor. They are normal and harmless, and do not require any intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.