A premature infant was delivered after a prolonged labor with ...

[haleyc112]

A premature infant was delivered after a prolonged labor with rupture of the maternal membranes >18 hours. The infant's weight is 6 lb, 1 oz (2.75 kg). What assessment finding would require the nurse to intervene immediately?
 
  A.
  Blood pressure reading of 60/35 mm Hg
  B.
  Skin temperature reading of 96.8 F (36 C)
  C.
  Unconjugated bilirubin level of 1.0 mg/dL
  D.
  White blood cell count of 12,500/mm3

Question 2

A pediatric nurse sees a baby with microcephaly. What action is most important for this nurse to do?
 
  A.
  Assess the baby's feeding abilities with an adapted nipple.
  B.
  Document head circumference at each visit.
  C.
  Document weight gain at each visit.
  D.
  Review medication administration with parents.

[kjo;oj]

Answer to Question 1

ANS: B
This infant is at risk for neonatal sepsis. Signs of this condition include hyperthermia or hypothermia, lethargy, hypoglycemia, and poor feeding. This child's skin temperature reading is below normal, requiring the nurse to intervene. The blood pressure reading is normal for a child of this weight. The two laboratory values are also normal.

Answer to Question 2

ANS: B
A baby with microcephaly has a head circumference 2 standard deviations below the mean for gestational age. It is crucial for the nurse to accurately and consistently measure and document the baby's head circumference at each visit. The baby does not need a special nipple. Documenting weight gain is important for every baby, but is not specific for this condition. There are no medications used to treat this condition.