A nurse is caring for a neonate in the neonatal intensive care unit. Q122

Exhibits

Which findings in the client's electronic medical record (EMR) are risk factors for the client developing a complication? Select all that apply.

Abdominal circumference

Gestational age

Respiratory distress

UAC

Feeding method

5-minute Apgar score

Answer and Explanation

Correct Answer : A,B,C,D

A. Abdominal circumference: The increase in abdominal circumference by 1 cm (0.4 in) since the prior assessment is concerning and may indicate a complication such as abdominal distension, which could be a sign of necrotizing enterocolitis (NEC) or other gastrointestinal issues. NEC is a serious condition that is common in preterm infants, especially those receiving enteral feedings.

B. Gestational age: Being born at 34 weeks gestation is a significant risk factor. Prematurity increases the risk for complications like respiratory distress syndrome (RDS), infections, and feeding difficulties. Preterm infants are also at risk for problems with thermoregulation, which is why the neonate is on a radiant warmer.

C. Respiratory distress: The presence of substernal retractions, nasal flaring, and an elevated respiratory rate (70/min) indicates respiratory distress. Preterm neonates, especially those born at 34 weeks, are at risk for RDS due to insufficient surfactant production, which can lead to difficulty breathing and hypoxemia.

D. UAC: The umbilical arterial catheter (UAC) is commonly used for monitoring blood pressure and obtaining blood samples in neonates. However, it carries a risk for complications such as infection, thrombosis, and injury to blood vessels. This is an invasive device that could contribute to complications.

E. Feeding method (Continuous breast milk feedings via OG tube): Although feeding via an orogastric tube is a standard method for preterm neonates, it does not pose an immediate risk factor in this case. The method of feeding itself is not a complication risk. However, complications like feeding intolerance or aspiration can arise, which would require further monitoring.

G. 5-minute Apgar score: A 5-minute Apgar score of 7 is considered an acceptable score for a neonate. Although it indicates some initial difficulty, this score does not present a significant risk factor for complications by itself. A lower score would be more concerning, but a score of 7 typically suggests the neonate is transitioning well.

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Correct Answer is C

Explanation

A. Provide a tracheostomy tray at the bedside: Incorrect. A tracheostomy tray is not necessary unless the client has a tracheostomy, which is not typically indicated for seizure precautions.

B. Place the client in supine position: Incorrect. The client should be placed on their side to prevent aspiration and promote airway patency during and after a seizure.

C. Insert an IV saline lock: A saline lock is essential in case the client needs emergency medication or fluids, especially during or after a seizure. It allows for quick IV access without continuous infusion.

D. Place a plastic tongue depressor at the client's bedside: Incorrect. A tongue depressor should never be inserted into the mouth during a seizure as it can lead to injury. The priority is to protect the client’s airway and prevent harm.

A. feeling short of breath B. pleuritic chest pain C. headache for the past 3 days D. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast E. pleuritic chest pain as 6 on a scale of 0 to 10 F. Lungs sounds are diminished in lower lobes with crackles G. nausea

Correct Answer is ["A","B","C","F"]

Explanation

Feeling short of breath:

Rationale: Shortness of breath is a critical symptom, especially in a client with a recent diagnosis of pneumonia (right lower lobe pneumonia seen on chest x-ray). It indicates impaired gas exchange and requires immediate evaluation to ensure the client’s oxygenation needs are being met and that the condition isn’t worsening. Given the oxygen saturation was 88%, this symptom is concerning and requires prompt intervention, such as increasing oxygen therapy.

Pleuritic chest pain:

Rationale: Pleuritic chest pain, often described as sharp or stabbing pain that worsens with breathing or coughing, is commonly associated with conditions like pneumonia or pulmonary embolism. In this case, the client has pneumonia, which can cause inflammation of the pleura (the lining of the lungs) and lead to pain. This symptom requires monitoring and potentially further evaluation to assess the extent of the pneumonia and its complications.

Headache for the past 3 days:

Rationale: A headache lasting several days could be related to the underlying infection or a systemic response to it (fever, dehydration, etc.). Although a headache is not an immediate emergency, it may indicate that the infection is severe or complicated, especially in the context of fever and other systemic symptoms like nausea. It is important to monitor the client's neurological status as part of their overall condition.

Nausea:

Rationale: Nausea, especially in the setting of a respiratory infection like pneumonia, can indicate that the infection is affecting the gastrointestinal system or could be a side effect of medications (e.g., antibiotics). It is important to evaluate the cause of the nausea and address any concerns related to fluid and electrolyte balance, particularly because the client has not been eating well, which could lead to dehydration or malnutrition.

Lung sounds diminished in lower lobes with crackles:

Rationale: Diminished lung sounds with crackles suggest fluid or consolidation in the lungs, which is characteristic of pneumonia. This finding requires immediate attention because it could indicate worsening pneumonia or atelectasis. Monitoring and interventions, such as increased oxygen support, encouraging deep breathing, and using the incentive spirometer, are essential to prevent further respiratory decline.

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A nurse is caring for a neonate in the neonatal intensive care unit. Q122 Exhibits Which findings in the client's electronic medical record (EMR) are risk factors for the client developing a complication? Select all that apply.

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A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","F"]

Explanation

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A nurse is caring for a neonate in the neonatal intensive care unit. Q122

Exhibits

Which findings in the client's electronic medical record (EMR) are risk factors for the client developing a complication? Select all that apply.