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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Respiratory Status: The newborn is exhibiting signs of respiratory distress, including a respiratory rate of 100/min, grunting, nasal flaring, and substernal retractions. These findings indicate compromised respiratory function, which requires immediate attention to prevent hypoxemia or respiratory failure. The diffuse radiopaque areas on the chest x-ray suggest a condition like transient tachypnea of the newborn (TTN) or respiratory distress syndrome (RDS), common in low-birth-weight infants.

Temperature: After stabilizing the respiratory status, addressing the newborn’s temperature is important. The temperature of 36.3°C (97.3°F) indicates mild hypothermia, which can further compromise respiratory function and glucose metabolism if not corrected. Warming the infant with skin-to-skin contact or using a radiant warmer is necessary to maintain thermoregulation.

A. Explain that this is an acceptable weight loss for this time. B. Notify the healthcare provider of excessive weight loss. C. Take the infant to the intensive care unit for an intravenous line. D. Advise the mother to supplement each breastfeeding with formula.

Correct Answer is A

Explanation

A. It is normal for newborns to lose up to 10% of their birth weight in the first few days. This weight loss is primarily due to fluid shifts and will resolve with regular breastfeeding.

B. Weight loss in this range is not excessive and does not require immediate intervention.

C. There is no indication for intensive care based on this weight loss alone.

D. Supplementing with formula is not necessary unless weight loss exceeds 10% or breastfeeding is inadequate.

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The nurse is caring for a preterm formula fed infant. What finding would be most important to report to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who was born at 38 weeks of gestation. Exhibits A nurse is initiating the newborn's plan of care. Complete he following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

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Correct Answer is A

Explanation

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