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 B

Explanation

Jaundice in an infant who is 4-hr old. This is because jaundice is a yellow discoloration of the skin and eyes caused by high levels of bilirubin in the blood. Jaundice usually appears between the second and fourth day after birth and lasts for one to two weeks. Jaundice that appears within the first 24 hours of life is considered early-onset jaundice and may indicate a serious problem, such as an infection, a blood type mismatch, or a liver disorder. The nurse should notify the charge nurse of this finding and request a blood test to check the bilirubin level.

Choice A is wrong because a hematocrit of 60% in an infant who is 8-hr old is not abnormal. Hematocrit is the percentage of red blood cells in the blood. Newborns normally have higher hematocrit levels than older children and adults because they have more red blood cells at birth.

Choice C is wrong because a blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old is not abnormal.

Blood glucose is the amount of sugar in the blood. Newborns normally have lower blood glucose levels than older children and adults because they have less glycogen (stored sugar) at birth.

Choice D is wrong because acrocyanosis in an infant who is 2-hr old is not abnormal. Acrocyanosis is a bluish discoloration of the hands and feet caused by poor circulation. Newborns normally have acrocyanosis for the first few days of life because they are adjusting to the temperature outside the womb.

A. Endometritis B. Cystitis C. Dehydration D. Hypovolemic shock

Correct Answer is A

Explanation

Endometritis. This is because the client's symptoms suggest that she has endometritis, which is an infection of the lining of the uterus. Endometritis is a common postpartum complication that can occur after vaginal or cesarean delivery. The client may also have foul-smelling vaginal discharge, chills, and fatigue.

Choice B is wrong because cystitis is an infection of the bladder that causes pain or burning during urination, not cramping.

Choice C is wrong because dehydration does not cause fever or persistent cramping.

Choice D is wrong because hypovolemic shock is a condition of low blood volume that causes low blood pressure, rapid pulse, and pale skin, not fever or cramping.

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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 several newborn clients. For which of the following findings should the nurse notify the charge nurse?

Correct Answer is B

Explanation

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

Correct Answer is A

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.

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?

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:

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?

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?