The parents of a 24-week preemie who is in the neonatal intensive care unit (NICU) are visiting their baby.
The newborn is intubated, receiving mechanical ventilation, TPN, intravenous fluids and medications, and is being monitored electronically by various devices.
What action by the nurse would be the most appropriate at this time?
Reassure the parents that the newborn is doing well.
Provide discharge teaching on SIDS prevention.
Discuss topics such as diapering, skin, and umbilical cord care.
Emphasize the importance of pumping breast milk for when the infant begins enteral feedings.
The Correct Answer is D
Choice A rationale
Simply reassuring the parents does not provide them with actions they can take to support their baby's care. While reassurance is important, it must be paired with practical advice that empowers the parents and involves them in the baby's care.
Choice B rationale
Discharge teaching on SIDS prevention is essential but is premature for parents with a 24-week preemie in NICU. The immediate focus should be on supporting them with current care practices and preparing them for future involvement in their baby's daily needs.
Choice C rationale
Discussing diapering, skin, and umbilical cord care is important, but it is not the immediate priority in the NICU context. Parents need guidance on how to support their baby’s current complex care needs rather than routine newborn care at this stage.
Choice D rationale
Emphasizing the importance of pumping breast milk is the most appropriate action. Breast milk is crucial for the baby's nutrition and immune support once enteral feedings begin. This action empowers the parents to actively contribute to their baby's care and prepares for future needs. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
If the client and the newborn are both Rh positive, Rh immunoglobulin is not necessary because there is no Rh incompatibility.
Choice B rationale
Rh immunoglobulin is administered when the mother is Rh negative and the newborn is Rh positive to prevent the mother's immune system from developing antibodies against Rh-positive blood.
Choice C rationale
If the client is Rh positive and the newborn is Rh negative, Rh immunoglobulin is not needed because Rh incompatibility does not occur in this scenario.
Choice D rationale
If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, so Rh immunoglobulin is not needed.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Respiratory assessment is crucial postpartum, especially with an elevated respiratory rate. It helps detect any respiratory distress or complications early.
Choice B rationale
Hemoglobin level assessment is essential to identify anemia or excessive blood loss during delivery, which can compromise the mother's health.
Choice C rationale
A heart rate of 110/min is above the normal range and might indicate tachycardia, which requires monitoring and possibly intervention.
Choice D rationale
A constant trickle of blood at the vagina could indicate postpartum hemorrhage, necessitating immediate medical attention.
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