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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because phototherapy can damage the baby’s eyes and cause retinal injury.Eye pads should be used to protect the baby’s eyes from the light and should be removed every 4 hours to check for infection or injury.
Choice B is wrong because turning the lights off for ten minutes every hour would reduce the effectiveness of phototherapy and prolong the treatment time.Phototherapy aims to expose the baby’s skin to as much light as possible.
Choice C is wrong because clothing the baby in a shirt and diaper only would limit the amount of skin exposed to the light.The baby should be naked or wear only a diaper during phototherapy.
Choice D is wrong because tightly swaddling the baby in a baby blanket would also limit the amount of skin exposed to the light and increase the risk of overheating.The baby should be loosely wrapped or uncovered during phototherapy.
Correct Answer is D
Explanation
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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