To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Keep the infant's eyes covered at all times.

Position with the head slightly lower than the body.

Administer low concentrations of oxygen.

Monitor arterial oxygen levels with a pulse oximeter.

Answer and Explanation

The Correct Answer is C

Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.

Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.

Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.

Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.

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Correct Answer is D

Explanation

Massage the client’s fundus. This is because the most common cause of postpartum hemorrhage is uterine atony, which is the failure of the uterus to contract after delivery. Massaging the fundus can stimulate uterine contractions and reduce bleeding by compressing the blood vessels at the placental site.

Choice A is not correct because administering oxytocin is not the first action to take. Oxytocin is a medication that can also help the uterus contract, but it should be given after assessing the uterine tone and bleeding.

Choice B is not correct because observing for pooling of blood under the buttocks is not a priority action. It can help estimate the amount of blood loss, but it does not address the cause of bleeding or stop it.

Choice C is not correct because checking the client’s blood pressure is not the first action to take. Blood pressure can indicate hypovolemia due to blood loss, but it is not a sensitive indicator and may remain normal until a significant amount of blood is lost.

A. Prevent infection of the umbilical cord B. Prevent infection of the eyes from vaginal bacteria C. Protect tear ducts from vaginal bacteria D. Protect the urethra from fecal material

Correct Answer is B

Explanation

Prevent infection of the eyes from vaginal bacteria. This is because some newborns can be exposed to bacteria such as gonorrhea or chlamydia during delivery, which can cause a serious eye infection called gonococcal ophthalmia neonatorum (GON). Applying an antibiotic ointment such as erythromycin or ilotycin can prevent GON and other less severe eye infections by killing the bacteria.

Choice A is not correct because the umbilical cord does not need antibiotic ointment to prevent infection. It should be kept clean and dry until it falls off naturally.

Choice C is not correct because the tear ducts are not affected by vaginal bacteria. They are small tubes that drain tears from the eyes to the nose.
Choice D is not correct because the urethra is not a common site of infection for newborns. The urethra is the tube that carries urine from the bladder to the outside of the body.

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To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment.

Correct Answer is B

Explanation

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent?

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?