A nurse is assessing a pre-term newborn who has retinopathy of prematurity (ROP).
Which of the following manifestations should the nurse expect to observe?
Leukocoria (white pupils)
Strabismus (crossed eyes)
Nystagmus (involuntary eye movements)
All of the above
The Correct Answer is A
Leukocoria (white pupils) is a symptom of retinopathy of prematurity (ROP), an eye disease that can happen in premature babies. ROP happens when abnormal blood vessels grow on the retina, the light-sensitive layer of tissue in the back of the eye.
Choice B is wrong because strabismus (crossed eyes) is not a symptom of ROP, but a possible complication that can occur later in life.
Choice C is wrong because nystagmus (involuntary eye movements) is not a symptom of ROP, but another possible complication that can occur later in life.
Choice D is wrong because it includes choices B and C, which are incorrect.
Normal ranges for gestational age and birth weight are 38 to 42 weeks and 5.5 to 10 pounds, respectively. Babies born before 31 weeks or weighing less than 3 pounds are at risk for ROP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Magnesium sulfate is a tocolytic drug that inhibits uterine activity and relaxes smooth muscles.The goal of magnesium sulfate therapy for a client who is in pre-term labor is to stop or reduce the frequency and intensity of contractions.
Choice B is wrong because the client’s blood pressure decreases to within normal limits.
Magnesium sulfate is not an antihypertensive drug and does not lower blood pressure.It is used to prevent seizures in clients with preeclampsia or eclampsia.
Choice C is wrong because the client’s deep tendon reflexes are 2+.
This is a normal finding and does not indicate the effectiveness of magnesium sulfate therapy.A decrease or loss of deep tendon reflexes may indicate magnesium toxicity, which is a serious complication that requires immediate intervention.
Choice D is wrong because the client’s urine output increases to more than 30 mL/hr.
This is also a normal finding and does not indicate the effectiveness of magnesium sulfate therapy.A decrease in urine output may indicate renal impairment or magnesium toxicity, which are both adverse effects of the drug.
The normal range for serum magnesium level is 1.5 to 2.5 mEq/L or 1.8 to 3 mg/dL.The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL.
Correct Answer is B
Explanation
Blood pressure of 150/90 mmHg.This is because terbutaline can causeelevated blood pressureas a side effect.
The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.
Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline.Terbutaline can causefast or pounding heartbeatsas a common side effect.
Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals.Terbutaline can causetransient hyperglycemia(high blood sugar) as a serious side effect, but this is not the case here.
Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being.Terbutaline does not cause fever or hypothermia as a side effect.
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