To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Keep the infant's eyes covered at all times.

Position with the head slightly lower than the body.

Administer low concentrations of oxygen.

Monitor arterial oxygen levels with a pulse oximeter.

Answer and Explanation

The Correct Answer is C

Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.

Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.

Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.

Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.

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Correct Answer is A

Explanation

The Moro reflex was elicited. This is because the Moro reflex is a normal newborn reflex that occurs when the baby is startled by a loud noise or a sudden movement. The baby responds by extending the arms and legs, opening the hands, and then bringing the arms and legs back to the chest.

The Moro reflex is present at birth and disappears by 3 to 6 months of age.

Choice B is wrong because this is not abnormal for a full-term infant. The Moro reflex is a sign of a healthy nervous system and brain development.

Choice C is wrong because there is no evidence of an abnormality in the musculoskeletal system. The Moro reflex does not indicate any problems with the bones or muscles of the baby.

Choice D is wrong because the full-term infant should react to sudden movement. The Moro reflex is a protective response that helps the baby cling to the mother in case of danger.

A. asymmetrical chest movement B. respiratory rate of 50 breaths/minute C. acrocyanosis D. short periods of apnea (less than 15 seconds)

Correct Answer is A

Explanation

Asymmetrical chest movement is a sign of respiratory distress in the newborn, as it indicates unequal lung expansion or airway obstruction. A respiratory rate of 50 breaths/minute (choice B) is normal for a newborn, as is acrocyanosis (choice C), which is a bluish discoloration of the hands and feet due to immature peripheral circulation. Short periods of apnea (less than 15 seconds) (choice D) are also common and benign in newborns unless they are associated with bradycardia or cyanosis.

Choice B is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.

Choice C is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.

Choice D is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.

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To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

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Naxlex Comprehensive Predictor Exams

When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and the arms fanned out, and then both came back toward the midline. The nurse would interpret this behavior as:

Correct Answer is A

Explanation

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

Correct Answer is A

Explanation

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

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