An infant presents with lethargy in the newborn nursery on the ...

[gonzo233]

An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted.
 
  Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of:
 
  a. RDS.
  b. PIVH.
  c. BPD.
  d. ROP.

Question 2

Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?
 
  a. Hypothermia because of phototherapy treatment
  b. Impaired skin integrity related to diarrhea as a result of phototherapy
  c. Fluid volume deficit related to phototherapy treatment
  d. Knowledge deficit (parents) related to initiation of medical therapy

[perkiness]

Answer to Question 1

ANS: B
IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the eyes. Other physical characteristics are reported as being normal.

Answer to Question 2

ANS: C
Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for parents but physiologic needs take precedence.