A nurse is caring for a neonate in the neonatal intensive care unit.
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Nurses' Notes
1200:
The neonate is 3 days old. Lung sounds clear to auscultation. Frequent episodes of apnea, responds to tactile stimuli. Oxygen saturation 95% to 98% via nasal cannula. Neonate on radiant warmer.
Temperature 36.3° C (97.3° F)
Heart rate 158/min
Respiratory rate 70/min
Substernal retractions and nasal flaring noted. Orogastric (OG) tube placement verified. Continuous breast milk feedings via OG tube initiated 12 hr ago. The umbilical arterial catheter (UAC) site is clean, dry, and intact. Peripheral pulses 2+. Capillary refill brisk. Abdomen is soft, bowel sounds are present. Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment.
Lung sounds clear to auscultation
Frequent episodes of apnea
responds to tactile stimuli
Temperature 36.3° C (97.3° F)
Heart rate 158/min
Respiratory rate 70/min
Substernal retractions and nasal flaring noted
Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment
The Correct Answer is ["B","C","D","F","G","H"]
Frequent episodes of apnea, responds to tactile stimuli: Apnea in a neonate, especially one born preterm (at 34 weeks gestation), is not uncommon but should be carefully monitored. However, frequent apnea episodes may indicate an underlying respiratory issue, such as respiratory distress syndrome (RDS) or an infection. Apnea that requires tactile stimuli to resolve should be followed up with further assessment and possibly intervention.
Substernal retractions and nasal flaring: These are signs of respiratory distress. Substernal retractions and nasal flaring indicate the neonate is working harder to breathe, which may point to respiratory distress syndrome (RDS) or other respiratory compromise. Close monitoring and follow-up are necessary to assess the neonate's respiratory status and oxygenation.
Respiratory rate of 70/min: This is on the higher end for a neonate and may indicate respiratory distress or compensation for oxygenation issues. Close monitoring is required.
Temperature of 36.3 °C (97.3 °F): While this temperature is within the normal range for a neonate, it is on the lower end of the spectrum. Neonates, especially preterm ones, are at risk for hypothermia. The neonate is on a radiant warmer, which suggests that there may still be concerns regarding temperature regulation. This needs to be monitored closely to ensure proper thermal regulation.
Increased abdominal circumference by 1 cm (0.4 in): An increase in abdominal circumference can be a sign of feeding intolerance, such as necrotizing enterocolitis (NEC), or other gastrointestinal issues. It is important to continue monitoring for other signs of NEC or abdominal distension, which can indicate the need for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}
Explanation
Assessment Findings |
Sprain |
Fracture |
Dislocation |
Ecchymosis |
✅ |
✅ |
✅ |
Pain level |
✅ |
✅ |
✅ |
Edema |
✅ |
✅ |
✅ |
Sensation |
✅ |
✅ |
Rationale:
Ecchymosis (bruising):
Sprain: Common due to soft tissue damage.
Fracture: Frequently present due to bone and soft tissue injury.
Dislocation: Bruising often accompanies joint dislocation.
Pain level:
Sprain: Moderate pain, often exacerbated by movement.
Fracture: Pain is typically sharp and worsens with movement or weight-bearing.
Dislocation: Severe pain due to misalignment of the joint.
Edema:
Sprain: Common due to inflammation from ligament injury.
Fracture: Swelling is typical around the fracture site.
Dislocation: Edema occurs due to joint misalignment and tissue trauma.
Sensation (tingling):
Sprain: Nerve compression or irritation may cause tingling.
Fracture: Tingling can result from nerve involvement or swelling near the fracture site.
Dislocation: Tingling is less common unless nerve damage occurs, which is more serious and often leads to numbness or motor impairment.
Correct Answer is B
Explanation
A. Offer small amounts of clear liquids 6 hr following surgery: Typically, clear liquids can be introduced earlier if the child is awake and has no nausea.
B. Administer analgesics on a scheduled basis for the first 24 hr: Scheduled analgesia provides consistent pain relief, improving comfort and facilitating early mobilization, which is essential for preventing complications such as ileus or pneumonia.
C. Give cromolyn nebulized solution every 8 hr: Cromolyn is used for asthma, not postoperative care.
D. Apply a warm compress to the operative site once daily: Heat application to the surgical site is contraindicated as it may promote infection.
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