A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply.
Provide early feedings to prevent hypoglycemia
Maintain oxygen saturation parameters
Obtain hemoglobin and hematocrit laboratory tests
Monitor urinary output
Insert a peripheral IV
Correct Answer : A,B,C,D,E
A. Providing early feedings can help prevent hypoglycemia, a common complication of polycythemia.
B. Maintaining oxygen saturation parameters, which can indicate the adequacy of tissue oxygenation and perfusion.
C. Obtaining hemoglobin and hematocrit laboratory tests is essential for diagnosing and monitoring polycythemia.
D. Polycythemic neonates may have decreased urinary output due to reduced renal blood flow, dehydration, or increased risk of thrombosis. The nurse should monitor the urinary output and report any signs of oliguria, anuria, hematuria, or renal failure.
E. A peripheral IV is a catheter inserted into a vein to administer fluids, medications, or blood products. Polycythemic neonates may require a partial exchange transfusion, which is a procedure where some of the neonate's blood is removed and replaced with normal saline or donor blood. This can help lower the hematocrit and viscosity and improve oxygen delivery and tissue perfusion. The nurse should insert a peripheral IV and prepare for the transfusion as ordered by the physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Puzzles are more related to cognitive skills than gross motor skills.
B. Participation in sports often involves various gross motor activities such as running, jumping, and throwing, making it a relevant question for assessing gross motor skills.
C. Playing instruments primarily involves fine motor skills rather than gross motor skills.
D. Constructing models may involve some fine motor skills but is not necessarily indicative of gross motor skills.
Correct Answer is C
Explanation
A. Having the parent stand near and providing comfort measures, is not correct because it may not be enough to comfort the child or reduce anxiety during the procedure.
B. Using restraint or holding down the child during a procedure can increase anxiety, distress, and trauma, and is not recommended.
C. A saline lock is a device that allows access to a vein without having to insert a needle each time. This can reduce the number of painful procedures and lower the risk of infection or inflammation.
D. Numbing techniques can help reduce pain and discomfort during procedures and are typically used to enhance atraumatic care, especially for repeated procedures like blood draws or IV insertion. Therefore, avoiding them may not be beneficial.
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