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Exhibits

Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.

Blood type

Parents religious affiliation

Blood pressure

Level of consciousness

Hearing acuity

Heart rate

Deep tendon reflexes

Answer and Explanation

Correct Answer : A,D,F

A. Blood type: While important for transfusions, blood type is not relevant to assessing pain or determining appropriate pain management strategies. Pain assessment focuses on physiological and behavioral cues, not blood compatibility.
B. Parents’ religious affiliation: Religious beliefs may influence pain management preferences (e.g., preference for non-pharmacologic methods), but this is not a priority assessment before implementing pain management strategies. The immediate focus should be on assessing the infant’s pain level and physiological status.
C. Blood pressure: Pain can cause increased sympathetic nervous system activity, leading to elevated blood pressure. Monitoring blood pressure helps assess the severity of pain and guides appropriate pain management interventions.
D. Level of consciousness: Infants in significant pain may become restless, irritable, or inconsolable, while excessive sedation from pain medications can cause decreased responsiveness. Assessing level of consciousness helps ensure that pain relief measures do not cause over-sedation or respiratory depression.
E. Hearing acuity: Hearing assessment is not relevant for pain management in a 4-month-old infant. Pain assessment in infants focuses on physiological signs, crying, and behavioral responses, rather than auditory abilities.
F. Heart rate: Pain can lead to tachycardia due to sympathetic nervous system activation. Monitoring heart rate helps assess pain intensity and evaluate the effectiveness of pain relief interventions.
G. Deep tendon reflexes: Reflex testing is used for neurological assessment but is not relevant to pain management. Reflexes do not provide direct information about pain intensity or response to treatment.

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Correct Answer is D

Explanation

A. Give blow-by oxygen via cannula. Blow-by oxygen is used for neonates who are breathing spontaneously but need supplemental oxygen. Since this newborn remains apneic despite stimulation, oxygen alone will not be sufficient to establish effective respiration.
B. Start IV infusion in a scalp vein. IV access may be needed later for medications or fluids, but the immediate priority is establishing effective breathing. Without adequate ventilation, oxygen delivery to tissues will be compromised, making IV interventions secondary.
C. Assist neonatologist with intubation. Intubation is reserved for neonates who fail to respond to positive pressure ventilation (PPV) or who require prolonged respiratory support. Since this newborn has a heart rate of 100 bpm and is apneic, PPV should be initiated first to stimulate breathing before considering intubation.
D. Provide positive pressure ventilation. PPV is the priority intervention for a newborn who remains apneic despite initial stimulation. A heart rate of 100 bpm is reassuring, but without spontaneous breathing, PPV is necessary to ensure adequate oxygenation and prevent further deterioration. Neonatal resuscitation guidelines recommend starting PPV within the first minute of life if the infant does not establish effective respirations.

A. Folic acid. B. Iron. C. Vitamin D. D. Calcium.

Correct Answer is A

Explanation

A. Folic acid. Folic acid is essential for neural tube development and significantly reduces the risk of neural tube defects (NTDs) such as anencephaly and spina bifida. Women planning to conceive should take at least 400–800 mcg of folic acid daily, beginning before conception and continuing during early pregnancy, to support proper neural tube closure.
B. Iron. Iron is important for preventing maternal anemia and supporting fetal growth, but it does not play a direct role in neural tube development. While iron supplementation is recommended during pregnancy, it does not prevent neural tube defects such as anencephaly.
C. Vitamin D. Vitamin D is crucial for calcium absorption and fetal bone development but does not impact neural tube formation. Deficiency can lead to rickets in newborns, but it is not associated with neural tube defects.
D. Calcium. Calcium supports maternal bone health and fetal skeletal development but does not influence neural tube formation. While necessary for overall pregnancy health, calcium supplementation does not prevent anencephaly or other NTDs.

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Exhibits Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

Correct Answer is A

Explanation

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Exhibits

Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.