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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A white blood cell count of 12,000/mm3 indicates an infection that can trigger pre-term labor.The normal range for white blood cell count in pregnancy is 5.7-15.0×10 9 /L, which is equivalent to 5,700-15,000/mm3.

A count above this range suggests an inflammatory response to an infection.

Choice B is wrong because a hemoglobin level of 11 g/dL is within the normal range for pregnancy, which is 10-14 g/dL.

Choice C is wrong because a platelet count of 250,000/mm3 is within the normal range for pregnancy, which is 150,000-400,000/mm3.

Choice D is wrong because a blood glucose level of 90 mg/dL is within the normal range for pregnancy, which is 70-110 mg/dL.

A. Referral to community services for support B. Encouragement to smoke in moderation C. Instructions for heavy lifting and strenuous exercise D. Recommendation to avoid kangaroo care

Correct Answer is A

Explanation

A. Referral to community services for support.

Referral to community services for support is an important part of the discharge plan for a client in preterm labor.Community services can provide education, counseling, home visits, and other resources to help the client cope with preterm labor and prevent complications.

B. Encouragement to smoke in moderation.Statement is wrong because smoking is harmful for the unborn baby and can increase the risk of preterm labor.Smoking should be avoided completely during pregnancy and the client should be advised to quit or seek help to quit.

C. Instructions for heavy lifting and strenuous exercise.Statement is wrong because heavy lifting and strenuous exercise can trigger contractions and worsen preterm labor.The client should be instructed to rest as much as possible and avoid activities that may cause uterine irritation or bleeding.

D. Recommendation to avoid kangaroo care.Statement is wrong because kangaroo care, or skin-to-skin contact with the baby, is beneficial for both the mother and the baby after birth.Kangaroo care can help regulate the baby’s temperature, heart rate, breathing, and blood sugar levels, as well as promote bonding, breastfeeding, and infection prevention.The client should be encouraged to practice kangaroo care as soon as possible after delivery.

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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?

Nursing Test Bank

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Correct Answer is A

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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?