The parents of a 24-week preemie who is in the neonatal intensive care unit (NICU) are visiting their baby.
The newborn is intubated, receiving mechanical ventilation, TPN, intravenous fluids and medications, and is being monitored electronically by various devices.
What action by the nurse would be the most appropriate at this time?
Reassure the parents that the newborn is doing well.
Provide discharge teaching on SIDS prevention.
Discuss topics such as diapering, skin, and umbilical cord care.
Emphasize the importance of pumping breast milk for when the infant begins enteral feedings.
The Correct Answer is D
Choice A rationale
Simply reassuring the parents does not provide them with actions they can take to support their baby's care. While reassurance is important, it must be paired with practical advice that empowers the parents and involves them in the baby's care.
Choice B rationale
Discharge teaching on SIDS prevention is essential but is premature for parents with a 24-week preemie in NICU. The immediate focus should be on supporting them with current care practices and preparing them for future involvement in their baby's daily needs.
Choice C rationale
Discussing diapering, skin, and umbilical cord care is important, but it is not the immediate priority in the NICU context. Parents need guidance on how to support their baby’s current complex care needs rather than routine newborn care at this stage.
Choice D rationale
Emphasizing the importance of pumping breast milk is the most appropriate action. Breast milk is crucial for the baby's nutrition and immune support once enteral feedings begin. This action empowers the parents to actively contribute to their baby's care and prepares for future needs. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Positive Moro and stepping reflexes are normal findings in newborns and are not specifically associated with dehydration or SGA.
Choice B rationale
Scant vernix is common in full-term babies and not indicative of SGA or dehydration.
Choice C rationale
Blood glucose levels provided are within normal range for newborns and do not indicate dehydration.
Choice D rationale
Tenting of the skin and dry lips are signs of dehydration, which can be associated with SGA newborns due to insufficient fluid intake. .
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Axillary temperature of 36.1°C (97°F) is within the normal range for a newborn. It does not necessarily indicate a problem that requires follow-up. Temperature regulation in newborns can vary, and this value is not concerning.
Choice B rationale
Respiratory rate of 78/min is higher than the normal range for newborns (30-60 breaths per minute). This could indicate respiratory distress and requires follow-up to determine the underlying cause.
Choice C rationale
Nasal flaring is a sign of respiratory distress in newborns. It indicates that the baby is having difficulty breathing and requires immediate follow-up to assess the severity and provide appropriate interventions.
Choice D rationale
A fontanel that is level and soft with a large ecchymotic tinge could indicate bruising or trauma. This finding is unusual and requires follow-up to determine the cause and ensure there is no underlying issue that needs to be addressed.
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