A nurse is planning care for a pre-term newborn who has a diagnosis of intraventricular hemorrhage (IVH).
Which of the following interventions should the nurse include in the plan?
Monitor vital signs and neurological status frequently
Administer antibiotics as prescribed
Elevate the head of the bed to 30 degrees
Provide supplemental oxygen as needed
The Correct Answer is A
Monitor vital signs and neurological status frequently.
This is because intraventricular hemorrhage (IVH) is a common and serious complication of prematurity that can lead to hydrocephalus, cerebral palsy, and developmental delays. Monitoring vital signs and neurological status can help detect changes in intracranial pressure, bleeding, and infection.
Choice B is wrong because antibiotics are not indicated for IVH unless there is evidence of infection.
Choice C is wrong because elevating the head of the bed to 30 degrees can increase the risk of IVH by reducing cerebral perfusion pressure and causing venous congestion.
Choice D is wrong because supplemental oxygen is not recommended for IVH unless there is hypoxia or respiratory distress. Excessive oxygen can cause oxidative stress and vasoconstriction, which can worsen IVH.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
White blood cell count 25,000/mm3.
This indicates a potential complication of necrotizing enterocolitis (NEC), which is the death of intestinal tissue in premature or sick newborns.A high white blood cell count can be a sign of infection or inflammation in the bowel, which are common features of NEC.
Choice A is wrong because hematocrit 45% is within the normal range for newborns.
Hematocrit measures the percentage of red blood cells in the blood.
A low hematocrit can indicate blood loss or anemia, which can be complications of NEC, but a normal hematocrit does not rule out NEC.
Choice B is wrong because platelets 150,000/mm3 is also within the normal range for newborns.
Platelets are cells that help the blood clot.A low platelet count can indicate a consumption coagulopathy, which is a bleeding disorder that can occur in severe cases of NEC.
However, a normal platelet count does not exclude NEC.
Choice D is wrong because blood glucose 80 mg/dL is also within the normal range for newborns.
Blood glucose measures the amount of sugar in the blood.
A low blood glucose can indicate hypoglycemia, which can be caused by sepsis or other conditions that mimic NEC, but a normal blood glucose does not eliminate NEC.
Correct Answer is C
Explanation
This medication will help relax my uterus and stop contractions.
Magnesium sulfate is a tocolytic, a medication used to suppress uterine contractions and delay preterm delivery.The exact mechanism through which magnesium sulfate inhibits contractions is unknown, but researchers believe it likely works by lowering calcium levels in the uterine muscles.
Choice A is wrong because magnesium sulfate is not used to prevent seizures in case of preeclampsia.
Preeclampsia is a condition characterized by high blood pressure and protein in the urine during pregnancy.Magnesium sulfate may be used to treat seizures if they occur with eclampsia, which is a severe complication of preeclampsia.
Choice B is wrong because magnesium sulfate does not help mature the baby’s lungs in case of preterm birth.
Magnesium sulfate may have some neuroprotective effects for the baby, but it does not affect lung development.Steroids are usually given to pregnant women at risk of preterm delivery to help accelerate fetal lung maturation.
Choice D is wrong because magnesium sulfate does not lower blood pressure in case it gets too high.
Magnesium sulfate may have some vasodilatory effects, but it is not used as an antihypertensive agent.Other medications, such as hydralazine or labetalol, are used to treat high blood pressure during pregnancy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.