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 A
Explanation
A. At 9 months of age, babies are able to crawl and explore their environment. They may pick up and put anything in their mouth, which can cause choking or poisoning. Therefore, the nurse should warn the mother about keeping the floor clear of small objects, such as coins, buttons, beads, or toys with detachable parts.
B. Safety procedures during baths are crucial, but this topic may have been covered in earlier visits or could be discussed alongside creating a toddler-safe home.
C. This more relevant for older babies or toddlers who can stand, walk, or climb.
D. Cautioning about putting the baby in a walker is important, but it may not be the most immediate concern at 9 months, as many babies start using walkers around 6-9 months. Creating a safe home environment encompasses a broader range of potential hazards.
Correct Answer is A
Explanation
A. Before answering questions, it's important to understand what the child already knows or thinks about the subject to provide developmentally appropriate information.
B. Expanding upon the topic when answering questions may overwhelm the child with too much information and may not be developmentally appropriate.
C. Providing a less than honest response may undermine trust between the parent and child and may not adequately address the child's curiosity or concerns.
D. Waiting until the child asks about a topic may miss opportunities for proactive, age-appropriate education and guidance.
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