11. The nurse caring for a very low–birth-weight (VLBW) newborn : 1361475.
11. The nurse is caring for a very low–birth-weight (VLBW) newborn with a peripheral intravenous infusion. Which statement describes nursing considerations regarding infiltration?
a. Infiltration occurs infrequently because VLBW newborns are inactive.
b. Continuous infusion pumps stop automatically when infiltration occurs.
c. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
d. Infusion site should be checked for infiltration at least once per 8-hour shift.
12. The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?
a. Elevate feet 15 degrees.
b. Place socks on newborn.
c. Wrap feet loosely in prewarmed blanket.
d. Report findings immediately to the practitioner.
13. The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse should explain that breastfeeding can be initiated when her newborn:
a. achieves a weight of at least 3 pounds.
b. indicates an interest in breastfeeding.
c. does not require supplemental oxygen.
d. has adequate sucking and swallowing reflexes.
14. Which is the most appropriate nursing action when intermittently gavage-feeding a preterm newborn?
a. Allow formula to flow by gravity.
b. Insert tube through nares rather than mouth.
c. Avoid letting newborn suck on tube.
d. Apply steady pressure to syringe to deliver formula to stomach in a timely manner.
15. A healthy, stable, preterm newborn will soon be discharged. The nurse should recommend which position for sleep?
c. Side lying
d. Position of comfort
16. Which intervention should the nurse implement to maintain the skin integrity of the premature newborn?
a. Cleanse skin with a gentle alkaline-based soap and water.
b. Cleanse skin with a neutral pH solution only when necessary.
c. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
d. Avoid cleaning skin.
17. Which is an important nursing action related to the use of tape and/or adhesives on premature newborns?
a. Avoid using tape and adhesives until skin is more mature.
b. Use solvents to remove tape and adhesives instead of pulling on skin.
c. Remove adhesives with warm water or mineral oil.
d. Use scissors carefully to remove tape instead of pulling tape off.
18. The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital signs and changing the newborn’s diaper, the nurse observes the newborn’s color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of:
b. subtle seizures.
c. preterm behavior.
d. onset of respiratory distress.
19. When is the best time for the neonatal intensive care unit (NICU) nurse to initiate an individualized stimulation program for the preterm newborn?
a. As soon as possible after newborn is born
b. As soon as parent is available to provide stimulation
c. When newborn is over 38 weeks of gestation
d. When developmental organization and stability are sufficient
20. A preterm newborn, after spending 8 weeks in the NICU, is being discharged. The parents of the newborn express apprehension and worry that the newborn may still be in danger. The nurse should recognize that this is:
b. a reason to postpone discharge.
c. suggestive of maladaptation.
d. suggestive of inadequate bonding.
11. The nurse caring for a very low–birth-weight (VLBW) newborn : 1361475