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 ["117"]
Explanation
The correct answer is 117 mL/hr.
To calculate the IV rate, the nurse should use the following formula:
IV rate (mL/hr) = (Volume to be infused (mL) / Time of infusion (hr)) x Drop factor (gtt/mL)
In this case, the volume to be infused is 350 mL, the time of infusion is 3 hr, and the drop factor is 1 gtt/mL (assuming the IV pump is calibrated in mL/hr). Therefore, the formula becomes:
IV rate (mL/hr) = (350 mL / 3 hr) x 1 gtt/mL
IV rate (mL/hr) = 116.67 mL/hr
The nurse should round the answer to the nearest whole number, which is 117 mL/hr.
Correct Answer is C
Explanation
Choice A reason: Glipizide is not an appropriate medication for the client, because it is a sulfonylurea that can cross the placenta and cause fetal hypoglycemia, hyperinsulinemia, and macrosomia. Glipizide is contraindicated in pregnancy.
Choice B reason: Acarbose is not an appropriate medication for the client, because it is an alpha-glucosidase inhibitor that can cause gastrointestinal side effects, such as flatulence, diarrhea, and abdominal pain. Acarbose is not recommended in pregnancy.
Choice C reason: Glyburide is an appropriate medication for the client, because it is a sulfonylurea that has a low placental transfer and a minimal risk of fetal hypoglycemia. Glyburide is considered safe and effective in pregnancy.
Choice D reason: Repaglinide is not an appropriate medication for the client, because it is a meglitinide that can cross the placenta and cause fetal hypoglycemia and teratogenic effects. Repaglinide is contraindicated in pregnancy.
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