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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A large bruise on the forehead of a 2-year-old could occur from accidental falls, which are common at this developmental stage due to increased mobility and decreased coordination. It does not necessarily suggest abuse unless accompanied by other suspicious findings.
Choice B rationale
Circular abrasions around the wrists are highly indicative of physical abuse as they suggest binding injuries. Restraining a child is neither acceptable nor normal, and such findings must be reported for further investigation by child protective services.
Choice C rationale
A burn on the palm of a 10-year-old’s hand raises concerns for abuse as accidental burns usually occur on accessible areas like arms or legs, not the palm. This pattern could indicate intentional infliction, requiring mandatory reporting to authorities.
Choice D rationale
Splash burns on the front torso in a 6-year-old are suspicious if inconsistent with the child’s developmental abilities or history provided by caregivers. Intentional scald burns often follow specific patterns, like splash marks, and must be reported for investigation.
Correct Answer is B
Explanation
Choice A rationale
A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.
Choice B rationale
Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.
Choice C rationale
Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.
Choice D rationale
An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.
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.