The nurse is caring for a 26-week-gestation infant diagnosed with periventricular hemorrhage and currently intubated. What is the most appropriate nursing action(s) for this infant?

Do not disturb the infant until the diaper is visibly soiled.

Frequent repositioning and use of a musical mobile.

Provide boundaries and dim the lights.

Administer morphine sulfate and gradually increase the gavage feeding amount.

Answer and Explanation

The Correct Answer is C

A. Delayed diaper changes can increase the risk of skin breakdown and infection.
B. Frequent repositioning and stimulation with a mobile may increase stress and intracranial pressure.
C. Minimizing stimulation, providing boundaries, and maintaining a calm environment (e.g., dim lighting) help reduce intracranial pressure and prevent further bleeding in infants with periventricular hemorrhage.
D. While pain management is important, feeding increases may exacerbate intracranial pressure and are not the priority.

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Correct Answer is D

Explanation

A. Closing the door reduces heat loss through convection, not evaporation.

B. Placing the crib near a warm wall reduces heat loss through radiation, not evaporation.

C. Warming equipment reduces heat loss through conduction, not evaporation.

D. Evaporation occurs when moisture on the newborn’s skin turns to vapor, causing heat loss. Drying the neonate immediately after birth and during baths is essential to prevent this.

A. Explain what colostrum is and offer to assist with latch. B. Call the physician for a prescription for formula. C. Obtain consent from her to use donor breast milk. D. Instruct her to burp after the baby eats 1/2 ounce.

Correct Answer is A

Explanation

A. Colostrum, the first form of breast milk, is produced in small amounts and is rich in nutrients and antibodies. Many new mothers are unaware of this and need reassurance.
B. Formula is not necessary unless medically indicated or the mother persists after being educated.
C. Donor breast milk is typically reserved for medically fragile infants.
D. Burping after feeding is important but does not address the client’s concern about milk supply.

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The nurse is caring for a 26-week-gestation infant diagnosed with periventricular hemorrhage and currently intubated. What is the most appropriate nursing action(s) for this infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Newborn heat loss through evaporation can be reduced by:

Correct Answer is D

Explanation

The nurse is caring for a 1-day postpartum client that is breastfeeding a healthy full-term newborn. The client requests a bottle of formula and verbalizes that she does "not have any milk". What is the most appropriate response?

Correct Answer is A

Explanation

A newborn is experiencing symptoms of cold stress. Which assessment data by the nurse will require further evaluation for stress protocol? (Select All that Apply.)

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The nurse recognizes mechanical stimuli involved with the transition to extrauterine pulmonary function includes:

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The nurse completing a gestational exam using the Ballard assessment tool understands that this assesses which two maturity components?

The nurse is caring for a 26-week-gestation infant diagnosed with periventricular hemorrhage and currently intubated. What is the most appropriate nursing action(s) for this infant?