Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:
A. Keep the infant's eyes covered at all times.
This 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.
B. Position with the head slightly lower than the body.
This 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.
C. Administer low concentrations of oxygen.
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.
D. Monitor arterial oxygen levels with a pulse oximeter.
This 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.
This question is an excerpt from Nurse Dive's nursing test bank - Postpartum AMD Newborn Care Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
A. asymmetrical chest movement
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.
B. respiratory rate of 50 breaths/minute
This is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.
C. acrocyanosis
This is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.
D. short periods of apnea (less than 15 seconds)
This is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.
Full 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.
The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?
A. Gastroesophageal reflux
This is incorrect because gastroesophageal reflux (GER) is a common condition in infants that causes them to spit up frequently after feeding. GER does not increase the risk of SIDS and can be managed by feeding smaller amounts, burping the infant often, and keeping them upright for a while after feeding.
B. Sudden infant death syndrome
Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS is more likely to occur when infants sleep on their stomachs or sides, or when they are propped up with pillows or other soft bedding. These positions can interfere with the infant's breathing and increase the risk of suffocation or overheating.
C. Apnea episodes
This is incorrect because apnea episodes are brief pauses in breathing that occur normally in infants, especially during sleep. Apnea episodes do not increase the risk of SIDS and usually resolve by six months of age.
D. Sleeping for short intervals
This is incorrect because sleeping for short intervals is normal for newborns, who need to feed frequently during the day and night. Sleeping for short intervals does not increase the risk of SIDS and will gradually change as the infant grows older.
Full Explanation
Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS is more likely to occur when infants sleep on their stomachs or sides, or when they are propped up with pillows or other soft bedding. These positions can interfere with the infant's breathing and increase the risk of suffocation or overheating .
Choice A is incorrect because gastroesophageal reflux (GER) is a common condition in infants that causes them to spit up frequently after feeding. GER does not increase the risk of SIDS and can be managed by feeding smaller amounts, burping the infant often, and keeping them upright for a while after feeding.
Choice C is incorrect because apnea episodes are brief pauses in breathing that occur normally in infants, especially during sleep. Apnea episodes do not increase the risk of SIDS and usually resolve by six months of age.
Choice D is incorrect because sleeping for short intervals is normal for newborns, who need to feed frequently during the day and night. Sleeping for short intervals does not increase the risk of SIDS and will gradually change as the infant grows older.
Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?
A. Physiologic jaundice
Physiologic jaundice usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.
B. Pathologic jaundice
This type of jaundice occurs within the first 24 hours of birth and is caused by an underlying health condition, such as blood type incompatibility, infection, or liver problems. It can lead to serious complications, such as brain damage, if not treated promptly.
C. Breast milk jaundice
This is not correct because breast milk jaundice is a rare condition that affects some breastfed babies. It usually appears after the first week of life and lasts up to a month or longer. It is caused by a substance in breast milk that interferes with the liver's ability to eliminate bilirubin.
Full Explanation
Physiologic jaundice usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.