A nurse is caring for a preterm infant who has intraventricular hemorrhage (IVH).
Which of the following actions should the nurse take to prevent increased intracranial pressure (ICP)?
Elevate the head of the bed to 30 degrees.
Avoid suctioning unless absolutely necessary.
Administer analgesics as prescribed.
All of the above.
The Correct Answer is D
All of the above.
The nurse should take all of the following actions to prevent increased intracranial pressure (ICP) in a preterm infant who has intraventricular hemorrhage (IVH):
• Elevate the head of the bed to 30 degrees. This helps to reduce venous congestion and improve cerebral blood flow.
• Avoid suctioning unless absolutely necessary. Suctioning can cause hypoxia, bradycardia, and increased ICP.
• Administer analgesics as prescribed. Pain can increase blood pressure and ICP.
Choice A is wrong because elevating the head of the bed alone is not enough to prevent increased ICP.
Choice B is wrong because avoiding suctioning alone is not enough to prevent increased ICP.
Choice C is wrong because administering analgesics alone is not enough to prevent increased ICP.
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Correct Answer is D
Explanation
This is because postmature babies lose the protective vernix that covers their skin in utero, and their skin becomes dry and cracked.Postmature babies also have less subcutaneous fat, which makes them look thin and wrinkled.
Choice A is wrong because postmature babies have less body fat than term babies, not more.They use up their fat stores to survive in the womb beyond 42 weeks of gestation.
Choice B is wrong because postmature babies have well-developed breast buds and areola, not flat ones.Breast development is a sign of fetal maturity that occurs around 36 weeks of gestation.
Choice C is wrong because postmature babies have less flexibility in their joints and muscles, not more.They have less amniotic fluid to cushion their movements, and their bones become more ossified as they grow older.
Normal ranges for gestational age are 37 to 42 weeks.Babies born before 37 weeks are considered preterm, and babies born after 42 weeks are considered postmature.
Correct Answer is A
Explanation
This statement indicates that the parent understands the signs of acute bilirubin encephalopathy, a serious complication of hyperbilirubinemia that can cause brain damage.
The parent should seek immediate medical attention if these symptoms occur.
Choice B is wrong because “I will keep my baby fully clothed and wrapped in blankets.” This statement indicates that the parent does not understand the role of phototherapy in treating hyperbilirubinemia.Phototherapy is a treatment wherein a baby is placed under a special blue spectrum light to reduce the bilirubin levels.The baby should be exposed to as much light as possible, with only the eyes and genitals covered.
Choice C is wrong because “I will limit breastfeeding to no more than 10 minutes per session.” This statement indicates that the parent does not understand the importance of adequate hydration and nutrition in preventing and treating hyperbilirubinemia.Breastfeeding should not be interrupted or limited, as it provides fluids and calories that help the baby excrete bilirubin through urine and stool.The American Academy of Pediatrics recommends breastfeeding at least 8 to 12 times per day for newborns.
Choice D is wrong because “I will avoid exposing my baby to sunlight or artificial light.” This statement indicates that the parent does not understand the difference between natural and artificial light sources for phototherapy.Sunlight or artificial light from lamps or windows are not effective or safe for treating hyperbilirubinemia, as they do not emit the right wavelength or intensity of light, and they can cause overheating, dehydration, sunburn, or eye damage.
The baby should receive phot
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