A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.
Which of the following actions should the nurse take
Diagnostic results
Escherichia coli infection resulting in necrotizing enterocolitis Hgb 10g/dL
Platelet count 50,000 mm
WBC count 4,000 mm3
The Correct Answer is A
The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the
abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
"Transmission can occur via the saliva and urine of the newborn." Maternal cytomegalovirus (CMV) is a viral infection that can be transmitted to the fetus during pregnancy or to the newborn during delivery or through breast milk. Lesions on the mother's genitalia are associated with herpes simplex virus, not CMV. Mothers with active CMV infection may not show any symptoms, and there is no specific prophylactic treatment with acyclovir for CMV infection. Airborne precautions are not necessary for newborns with CMV infection since the virus is primarily spread through contact with body fluids, such as saliva and urine.
Correct Answer is C
Explanation
The nurse should report a respiratory rate of 10/min to the provider following the administration of butorphanol IV bolus. Butorphanol is an opioid agonist-antagonist analgesic that can cause respiratory depression as a side effect. Therefore, it is important to monitor the client's respiratory rate and depth closely after administration of the medication. A respiratory rate of 10/min is significantly lower than the normal range of 1220/min, and may indicate respiratory depression. The nurse should also monitor the client's blood pressure, urinary output, and fetal heart rate for any changes, but these findings are not necessarily indicative of a complication following the administration of butorphanol.
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