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

Exhibits

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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

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Exclude nutritional supplements from the list of medications the client reports: Incorrect. Nutritional supplements are medications and should be included in the medication reconciliation process.

B. Encourage the client to make his own list after he returns to his home: Incorrect. The nurse should be responsible for gathering the complete medication history upon admission, not relying on the client’s list from home.

C. Compare new prescriptions with the list of medications the client reports: This is the correct step in medication reconciliation. The nurse needs to ensure that new medications are compatible with the client's current medications and review any changes.

D. Include any adverse effects of the medications the client might develop: Incorrect. Adverse effects are not part of the medication reconciliation process; the focus is on identifying all current medications, including prescriptions, over-the-counter drugs, and supplements.

A. Levothyroxine 75 mcg PO daily at 0600 B. Digoxin 250 PO daily C. Ceftriaxone 1 g IV Q 24 hours D. Acetaminophen 650 mg PO Q 6 hours

Correct Answer is B

Explanation

A. Levothyroxine is usually administered in the morning and is prescribed correctly here.

B. The prescribed dose of Digoxin 250 mcg is unusually high for a daily dose. Typically, digoxin is prescribed in lower doses, and the nurse should clarify this prescription with the provider to ensure it is correct.

C. Ceftriaxone is correctly prescribed as an IV antibiotic with a standard interval.

D. Acetaminophen is correctly prescribed as a dosage of 650 mg every 6 hours.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to a medical-surgical unit. When performing medication reconciliation for the client, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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