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.
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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Related Questions
Correct Answer is C
Explanation
A. Feed the infant at least 1 ounce of formula: Feeding may help if the baby is hungry, but it is not the first action in managing symptoms of NAS.
B. Collect a sterile urine specimen: This is an important step for diagnosing NAS but is not the immediate action to calm the infant.
C. Swaddle the infant with hands near its mouth: These symptoms are consistent with neonatal abstinence syndrome (NAS). Comfort measures such as swaddling and non-nutritive sucking are prioritized to soothe the infant.
D. Move the infant into a brightly lit area: A quiet, dim environment is better for soothing an overstimulated baby, so this action would be counterproductive.
Correct Answer is A
Explanation
A. The entry of air into the alveoli, replacing expelled amniotic fluid, is a critical mechanical stimulus that initiates the transition to neonatal breathing.
B. Decreased oxygen levels trigger chemical, not mechanical, stimuli.
C. The diaphragm moves downward during inspiration, not upward.
D. Drying and stimulation help initiate breathing through sensory stimulation, not mechanical.
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