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?

Keep the newborn in a well-lit nursery.

Cluster the newborn's care activities.

Use fingertips when calming the newborn.

Position the newborn to promote extension of muscles.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Keeping the newborn in a well-lit nursery may interfere with their ability to develop circadian rhythms, which are critical for growth and development. Premature newborns are particularly sensitive to environmental stress, and excessive lighting can disrupt their sleep-wake cycle, increasing stress and affecting neurological development.

Choice B rationale

Clustering care activities minimizes disruptions and allows the newborn to have longer periods of rest. This approach is vital for preterm infants, as uninterrupted sleep enhances brain growth, reduces energy expenditure, and promotes physiological stability, such as maintaining appropriate heart and respiratory rates.

Choice C rationale

Using fingertips when calming the newborn may not provide the soothing effects of a whole-hand approach. Gentle hand placement offers a more consistent pressure that mimics the containment provided in the womb, aiding in neuromuscular development and decreasing stress in preterm infants.

Choice D rationale

Positioning the newborn to promote muscle extension opposes the fetal position they naturally adopt and disrupts their physiological flexion posture. This posture facilitates stability and self-regulation and supports motor development, which is essential for preterm infants adjusting to life outside the womb.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Blue-gray discolorations on the sacrum, commonly known as Mongolian spots, are benign skin markings that frequently appear in newborns of Asian, African, and Hispanic descent. Documenting this finding ensures accurate medical records and prevents misinterpretation of these congenital marks as bruising.

Choice B rationale

There is no need to notify the healthcare provider about Mongolian spots unless there is uncertainty regarding their origin. These spots are non-pathological and typically fade within the first years of life, requiring no medical intervention or immediate attention.

Choice C rationale

Clotting studies are unnecessary for blue-gray discoloration because Mongolian spots are not related to blood clotting disorders. They are caused by the accumulation of melanocytes in the dermis during fetal development, a harmless pigmentation phenomenon.

Choice D rationale

Reporting parents to Child Protective Services in this context would be inappropriate and unjustified. Mongolian spots are a common and well-documented congenital skin feature, not indicative of abuse, and misinterpreting them could lead to undue stress and harm to the family. .

A. Weight gain. B. Mood changes. C. Weight loss. D. Chronic fatigue. E. Osteoporosis.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Weight gain is a common side effect of corticosteroids due to fluid retention and increased fat deposition. Corticosteroids stimulate appetite and alter fat metabolism, leading to central obesity and moon face, which are classic findings.

Choice B rationale

Mood changes, including irritability, depression, or euphoria, are linked to corticosteroid therapy as these medications affect the central nervous system. Neuropsychiatric symptoms can vary widely and may impact the adolescent’s quality of life and social interactions.

Choice C rationale

Weight loss is not a typical side effect of corticosteroids. These medications are more associated with increased appetite and fat redistribution, leading to weight gain rather than weight loss, making this an incorrect choice.

Choice D rationale

Chronic fatigue is not directly attributed to corticosteroids. While muscle weakness can occur due to protein catabolism, it is not synonymous with fatigue. Corticosteroids often cause insomnia, which could indirectly lead to tiredness, but this is not a primary effect.

Choice E rationale

Osteoporosis is a long-term side effect of corticosteroids due to their impact on calcium metabolism and bone resorption. These medications decrease calcium absorption, increase calcium excretion, and suppress osteoblast activity, leading to reduced bone density.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn.What is the most appropriate action for the nurse to take?

Correct Answer is A

Explanation

When caring for a 13-year-old with muscular dystrophy receiving corticosteroids to slow disease progression, which of the following medication side effects would you assess for?

Correct Answer is ["A","B","E"]

Explanation

A nurse is assessing a child who is in sickle cell crisis.Which of the following findings should the nurse expect?

A newborn is admitted with a diagnosis of a spiral fracture of the right femur.The mother states the child received the injury when the baby fell off the changing table.Which would be the priority nursing intervention?

When caring for a postpartum client, the nurse notes that the client's perineal pad is saturated with bright red blood.What is the priority to ask the client?

A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy.Which is the first nursing intervention to perform?

A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event.The child's caregiver expects the child to use an inhaler without supervision.The nurse can apply which of the following interventions as protective factors for the child?

The nurse is caring for a newborn diagnosed with patent ductus arteriosus (PD

Which of the following clients would the nurse report as a suspected abuse case?

Which assessment finding in a newborn places them at risk for physiological jaundice?

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?