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A nurse is caring for a neonate in the neonatal intensive care unit.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. The NG tube should be flushed with 15-30 mL of water before and after medication administration, not 5 mL.

B. Medications should not be added directly to enteral feeding as it may alter the medication's effectiveness or cause tube clogging.

C. Using a syringe to allow medications to flow by gravity reduces the risk of pressure-related complications and ensures safe administration.

D. Medications should be dissolved separately to prevent interactions or clogging.

A. Keeping a promise to visit with a client who is housebound after the delivery of care B. Being honest with the parents of a child about the need to report suspected abuse C. Accepting the decision of an older adult client to live alone in her home D. Ensuring that a client who is homeless receives preventive medical care

Correct Answer is D

Explanation

A. Keeping a promise to visit a housebound client reflects fidelity, not distributive justice.

B. Being honest with the parents about reporting suspected abuse demonstrates veracity.

C. Accepting a client's decision to live alone represents autonomy.

D. Ensuring equitable access to healthcare for a homeless client aligns with distributive justice, which focuses on the fair allocation of resources to all individuals, especially vulnerable populations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take?

Correct Answer is C

Explanation

A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?

Correct Answer is D

Explanation

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