The nurse is caring for a preterm formula fed infant. What finding would be most important to report to the healthcare provider?
No bowel movement within 12 hours.
Small regurgitation of undigested formula after feedings.
Abdominal distension.
Uncoordinated suck.
The Correct Answer is C
A. No bowel movement within 12 hours: While concerning, delayed stooling can occur in preterm infants and is not as urgent without additional symptoms like distension or bilious vomiting.
B. Small regurgitation of formula: Regurgitation is a common finding in preterm infants and typically not alarming unless persistent or associated with other symptoms like aspiration.
C. Abdominal distension: This finding may indicate necrotizing enterocolitis (NEC) or an obstruction, both of which are serious conditions requiring prompt medical attention.
D. Uncoordinated suck: This is expected in preterm infants due to immaturity and does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While concerning, delayed meconium passage can be monitored for a few more hours.
B. Newborns should void within 24 hours of birth. Failure to void may indicate renal issues or dehydration and requires immediate evaluation.
C. A temperature of 37.5° C is within the normal range for a newborn.
D. Acrocyanosis (bluish discoloration of the hands and feet) is normal in the first 24-48 hours after birth and typically resolves without intervention.
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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