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

This is because lochia rubra is the first stage of lochia, the vaginal discharge after giving birth. It comprises blood, shreds of fetal membranes, decidua, vernix caseosa, lanugo, and membranes. It is red in color because of the large amount of blood it contains. It lasts 1 to 4 days after birth.

Choice A is not correct because lochia alba is the last stage of lochia. It is whitish or yellowish-white in color and contains fewer red blood cells and more leukocytes, epithelial cells, cholesterol, fat, mucus, and microorganisms. It lasts from the second through the third to sixth weeks after delivery.

Choice B is not correct because there is no such thing as lochia normal. Lochia has three stages: lochia rubra, lochia serosa and lochia alba.

Choice C is not correct because lochia serosa is the second stage of lochia. It is brownish or pink in color and contains serous exudate, erythrocytes, leukocytes, cervical mucus, and microorganisms. It lasts for 4 to 12 days after delivery.

A. Squeeze out the white material after cleansing the face. B. Contact a pediatric dermatologist for topical medication C. Leave the milia alone: it will disappear spontaneously. No treatment is needed. D. Wash the baby's face with a mild astringent several times a day.

Correct Answer is C

Explanation

Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.

Choice A is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.

Choice B is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.

Choice D is incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.

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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

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?

Correct Answer is D

Explanation

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

Correct Answer is C

Explanation

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?

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

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

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:

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the body?

A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any:

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