A nurse is caring for a newborn who was born prematurely at 26 weeks. Which of the following interventions should the nurse take to decrease the newborn's risk of increased intracranial pressure?
Elevate the head of the bed 15° to 20°.
Stimulate the newborn every 2 hr.
Place the newborn in a radiant warmer.
Administer hypertonic solution.
The Correct Answer is A
Choice A rationale:
Elevating the head of the bed can help prevent intracranial pressure by promoting venous drainage from the head.
Choice B rationale:
Premature newborns need to rest and conserve energy, so excessive stimulation every 2 hours is not recommended.
Choice C rationale:
Placing the newborn in a radiant warmer helps maintain a stable body temperature, but it does not directly address intracranial pressure.
Choice D rationale:
Administering hypertonic solution is not a standard intervention for decreasing intracranial pressure in a premature newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Expressing feelings of guilt and survivor's guilt is a common aspect of processing traumatic experiences and can be an important step in healing.
Choice B rationale:
Rationale: This statement indicates that the client is acknowledging and discussing the flashbacks related to the traumatic event. Progression toward positive outcomes in posttraumatic stress disorder (PTSD) often involves recognizing and addressing distressing symptoms.
Choice C rationale:
The preference for independence may indicate resistance to seeking support, which can hinder progress in addressing and managing PTSD symptoms.
Choice D rationale:
Recognizing that the traumatic experience has affected the ability to trust others reflects insight into the impact of the trauma on relationships, which is a step toward positive outcomes.
Correct Answer is B
Explanation
Choice A rationale:
Upper abdominal pain is not a typical manifestation of diverticulitis. It is more commonly associated with conditions affecting the upper gastrointestinal tract.
Choice B rationale:
Rationale: Diverticulitis is characterized by inflammation or infection of diverticula (small pouches) in the colon. Manifestations of diverticulitis can include abdominal pain (usually left lower quadrant), fever, nausea, vomiting, and changes in bowel habits.
Abdominal distension may indicate worsening inflammation or complication of diverticulitis.
Choice C rationale: Clay-colored stools are more characteristic of liver or bile duct disorders, not diverticulitis.
Choice D rationale: Gastric reflux is not a common manifestation of diverticulitis. It is more related to gastroesophageal reflux disease (GERD) or other upper gastrointestinal issues.
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