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Exhibits

A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?

A.

Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr.

B.

Insert an orogastric decompression tube with low wall suction.

C.

Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.

D.

Administer nitric oxide inhalation therapy to the newborn.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Measuring the abdominal circumference at the level of the newborn's umbilicus every 12 hr is a critical action in this scenario. The newborn has necrotizing enterocolitis (NEC), a serious gastrointestinal condition, and measuring abdominal circumference can help monitor for changes in abdominal distention, which is a sign of NEC progression. 

Choice B rationale: 

Inserting an orogastric decompression tube with low wall suction may not be the most appropriate action for a newborn with NEC. While decompression tubes can be used in some cases of NEC, their insertion should be guided by specific clinical indications, and not all cases require them. 

Choice C rationale: 

Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated for NEC. NEC requires specialized medical management and treatment, which may include bowel rest and other interventions, but providing iron-rich formula is not one of them. 

Choice D rationale: 

Administering nitric oxide inhalation therapy is not relevant to the management of NEC. Nitric oxide inhalation therapy is used for respiratory conditions, particularly persistent pulmonary hypertension of the newborn, and does not address the gastrointestinal issues seen in NEC. 


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Related Questions

Correct Answer is C

Explanation

The correct answer is choice C: Verify that informed consent is obtained prior to administration. Choice A rationale: Placing the client in a semi-Fowler’s position is not specifically related to the administration of dinoprostone. This position is often used post-administration to promote comfort and labor progression, but it is not a required action prior to the administration of dinoprostone. Choice B rationale: Instructing the client to avoid urinary elimination until after administration is not necessary. There is no evidence to suggest that retaining urine affects the efficacy or safety of dinoprostone administration. Choice C rationale: Verifying that informed consent is obtained prior to administration is crucial. Dinoprostone, like any medication used to induce labor, carries potential risks and side effects. It is essential that the client is informed about these risks and consents to the procedure before the medication is administered. Choice D rationale: Allowing the medication to reach room temperature prior to administration is not a standard requirement for dinoprostone inserts. Medications have specific storage and administration guidelines that should be followed according to the manufacturer’s instructions and facility protocols.

Correct Answer is D

Explanation

Choice A rationale:

The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.

Choice B rationale:

Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.

Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.

Choice C rationale:

Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.

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