A nurse is assessing a premature newborn. Which assessment ...

[audie]

A nurse is assessing a premature newborn. Which assessment findings are consistent with prematurity? (Select all that apply.)
 
  a. Abundant lanugo over the body
  b. Ear cartilage soft and pliable
  c. Flexed body posture
  d. Deep creases on the sole of the foot
  e. Skin is bright pink, smooth, and shiny.

Question 2

A nurse is admitting a premature newborn to the NICU. Which interventions should the nurse implement to prevent retinopathy? (Select all that apply.)
 
  a. Place on pulse oximetry.
  b. Decrease exposure to bright, direct lighting.
  c. Place on a cardiac monitor.
  d. Cover eyes with an eye shield at night.
  e. Use supplemental oxygen only when needed.

[Dnite]

Answer to Question 1

ANS: A, B, E
The premature newborn has fine lanugo hair that is abundant over the body. The ear cartilage is soft and pliable, and the soles and palms have minimal creases, resulting in a smooth appearance. The premature newborn's skin is bright pink (often translucent, depending on the degree of immaturity), smooth, and shiny, with small blood vessels clearly visible underneath the thin epidermis. In contrast to full-term infants' overall attitude of flexion and continuous activity, preterm infants may be inactive and listless. The extremities maintain an attitude of extension and remain in any position in which they are placed.

Answer to Question 2

ANS: A, B, E
To prevent retinopathy, the nurse should provide preventive care by closely monitoring blood oxygen levels, responding promptly to saturation alarms, and preventing fluctuations in blood oxygen levels. Pulse oximetry is recommended to monitor the infant's oxygenation status during resuscitation and to prevent excessive use of oxygen in both term and preterm infants. Decrease exposure to bright, direct lighting; although exposure to bright light has not been proven to contribute to retinopathy of prematurity, such exposure is undesirable from a neurobehavioral developmental perspective. Use supplemental oxygen judiciously and monitor oxygen blood levels carefully; prevent wide fluctuations in oxygen blood levels (hyperoxia and hypoxia). Placing the newborn on a cardiac monitor will not prevent retinopathy. Covering the eyes with eye shields is not a preventive measure for retinopathy.