A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

Use fingertips when calming the newborn.

Position the premature infant on their abdomen.

Keep the newborn in a well-lit nursery.

Cluster the newborn's care activities.

Answer and Explanation

The Correct Answer is D

Choice A reason: Using fingertips when calming the newborn is not recommended, as it can overstimulate the immature nervous system and cause stress. Instead, the nurse should use gentle, firm, and sustained touch, such as cupping the head and feet, or swaddling the newborn.

Choice B reason: Positioning the premature infant on their abdomen is contraindicated, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should position the newborn on their back or side, with a rolled blanket or towel to support the spine and prevent flattening of the head.

Choice C reason: Keeping the newborn in a well-lit nursery is not advisable, as it can interfere with the development of the circadian rhythm and sleep patterns. The nurse should provide a dark and quiet environment for the newborn, and expose them to natural light during the day.

Choice D reason: Clustering the newborn's care activities is beneficial, as it can reduce the number of disruptions and allow for longer periods of rest and growth. The nurse should plan and coordinate the care activities, such as feeding, bathing, changing, and assessing, to minimize the stress on the newborn.

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Correct Answer is A

Explanation

Choice A reason: This statement is correct, as the ultrasound can help diagnose placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester. Placenta previa is a serious complication that can affect the delivery and the fetal oxygenation.

Choice B reason: This statement is incorrect, as the biparietal diameter is a measurement of the fetal head that is used to estimate the gestational age and the fetal growth. The biparietal diameter is not related to the cause or the severity of the bleeding.

Choice C reason: This statement is incorrect, as the fetal lung maturity is an assessment of the surfactant level in the amniotic fluid that is used to predict the risk of respiratory distress syndrome in preterm infants. The fetal lung maturity is not related to the cause or the severity of the bleeding.

Choice D reason: This statement is incorrect, as the viability of the fetus is an evaluation of the fetal heart rate, movement, and tone that is used to determine the fetal well-being and distress. The viability of the fetus is not related to the cause or the severity of the bleeding, although it can be affected by it.

A. To stay with the client and call for help B. To suction the mouth to prevent aspiration C. To administer oxygen by mask D. To insert an oral airway

Correct Answer is A

Explanation

Choice A reason: To stay with the client and call for help is the highest priority during a seizure, because it ensures the safety of the client and the fetus, and allows the nurse to monitor the vital signs and fetal heart rate. The nurse should also protect the client from injury and turn the client to the side to prevent aspiration.

Choice B reason: To suction the mouth to prevent aspiration is not the highest priority during a seizure, because it can cause more harm than good. Suctioning can stimulate the gag reflex and increase the risk of vomiting and aspiration. It can also injure the oral mucosa and trigger another seizure.

Choice C reason: To administer oxygen by mask is not the highest priority during a seizure, because it may not be effective or necessary. Oxygen administration can be difficult or impossible during a seizure, and it may not improve the oxygen saturation or fetal outcome. Oxygen should only be given if hypoxia is confirmed by pulse oximetry or arterial blood gas analysis.

Choice D reason: To insert an oral airway is not the highest priority during a seizure, because it can be dangerous and contraindicated. Inserting an oral airway can damage the teeth and tongue, and increase the risk of vomiting and aspiration. It can also provoke another seizure or laryngospasm. An oral airway should only be used if the client is unconscious and has no gag reflex.

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A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

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