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 A

Explanation

A. The nurse should dry the neonate immediately after birth to prevent heat loss, as newborns are at risk for hypothermia.
B. APGAR scoring is typically done 1 and 5 minutes after birth, not every 30 minutes during the 3rd stage of labor.
C. The neonatal assessment is usually performed after the delivery of the placenta, not during the 3rd stage of labor.
D. Blood samples for blood type are typically obtained after the newborn has stabilized, not during the 3rd stage of labor.

A. Closing the door to the room. B. Placing crib near a warm wall. C. Warming equipment used on the neonate. D. Drying the neonate.

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.

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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

The nurse is providing care for a neonate during the 3rd stage of labor. Which action does the nurse take during this stage?

Correct Answer is A

Explanation

Newborn heat loss through evaporation can be reduced by:

Correct Answer is D

Explanation

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