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 D

Explanation

A. Using a whole hand for gentle containment is more appropriate for calming preterm infants.
B. Promoting flexion, not extension, helps mimic the fetal position and provides comfort.
C. A dimly lit environment is preferred for preterm infants to reduce sensory overload.
D. Clustering care reduces stimulation and promotes rest, which is essential for preterm infant development and reducing stress.

A. Hemolysis of neonatal red blood cells by the maternal antibodies. B. Delayed meconium excretion resulting in the production of direct bilirubin. C. Pathological liver function resulting from hypoxemia during the birthing process. D. Physiological destruction of fetal red blood cells during the extrauterine period.

Correct Answer is D

Explanation

A. Hemolysis by maternal antibodies suggests hemolytic disease of the newborn (e.g., Rh incompatibility), which typically presents earlier and more severely.
B. Delayed meconium excretion may lead to increased bilirubin, but this is not the most common cause of jaundice at 3 days.
C. Pathological jaundice occurs within the first 24 hours or persists longer than a week.
D. Physiological jaundice is a common finding in newborns due to the natural breakdown of fetal red blood cells (RBCs) and the immature liver's inability to efficiently process bilirubin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

Correct Answer is D

Explanation

A 3-day-old infant is slightly jaundiced and has an elevated bilirubin level. What is the most probable cause for these changes?

Correct Answer is D

Explanation

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