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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.
Choice A is not correct because the client's milk will come in regardless of nursing frequency.
Choice B is not correct because the client's temperature is within normal limits.
Choice D is not correct because there is no indication of an increase in IV fluids.
Correct Answer is A
Explanation
This is because cephalhematoma is a collection of blood under the scalp that does not cross the suture line. It is caused by trauma to the head during delivery, such as from vacuum extraction or forceps. It usually appears within a few hours or days after birth and resolves within weeks or months.
Choice B is not correct because nevus flammeus is a type of birthmark that is also known as port-wine stain. It is a flat, red, or purple patch of skin that can appear anywhere on the body, but often on the face. It is caused by abnormal blood vessels in the skin and does not go away over time³.
Choice C is not correct because the molding is the temporary change in the shape of the head due to pressure during delivery. It does not cause swelling or bruising and usually resolves within a few days.
Choice D is not correct because caput succedaneum is a type of swelling that affects the scalp and crosses the suture line. It is caused by fluid accumulation under the scalp due to pressure during delivery. It usually appears at birth and goes away within a few days.
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