A preterm newborn is admitted to the neonatal intensive care with the diagnosis of an omphalocele. What nursing actions would the nurse perform? Select all that apply.

Fluid loss of the neonate will be minimized.

Neonatal weight loss will be prevented.

Assessment of hyperbilirubinemia will be monitored.

Perfusing to the exposed abdominal contents will be maintained.

The abdominal contents are protected.

Answer and Explanation

Correct Answer : A,D,E

A.   Minimizing fluid loss is important in the care of a neonate with an omphalocele to prevent dehydration.
B.   Preventing neonatal weight loss is not directly related to the care of an omphalocele.
C.   While monitoring for hyperbilirubinemia is important in neonatal care, it's not specific to the care of an omphalocele.
D.   Maintaining perfusion to the exposed abdominal contents is essential for preventing complications such as ischemia or necrosis.
E.   Protecting the abdominal contents helps prevent infection and trauma to the exposed organs.

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Correct Answer is B

Explanation

A. Changing routines frequently might confuse the child rather than stimulate initiative.
B. Rewarding the child for showing initiative positively reinforces the behavior and encourages further development.
C. Allowing the child to make choices about playmates can foster independence but may not directly stimulate initiative.
D. Setting appropriate limits is important for a child's development, but not setting any limits can lead to behavioral issues rather than promoting initiative.

A. Have the parent stand near and/or rub the child's feet during the procedure. B. Use restraint or "holding down" of the child during the procedure to prevent injury. C. Insert a saline lock if the child will require multiple doses of parenteral medications. D. Avoid using numbing techniques for multiple blood draws or IV insertion.

Correct Answer is C

Explanation

A. Having the parent stand near and providing comfort measures, is not correct because it may not be enough to comfort the child or reduce anxiety during the procedure.
B. Using restraint or holding down the child during a procedure can increase anxiety, distress, and trauma, and is not recommended.
C. A saline lock is a device that allows access to a vein without having to insert a needle each time. This can reduce the number of painful procedures and lower the risk of infection or inflammation.
D. Numbing techniques can help reduce pain and discomfort during procedures and are typically used to enhance atraumatic care, especially for repeated procedures like blood draws or IV insertion. Therefore, avoiding them may not be beneficial.

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A preterm newborn is admitted to the neonatal intensive care with the diagnosis of an omphalocele. What nursing actions would the nurse perform? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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