NURS 111 Premature Infant Exam. Meet the Client: Jamie Fargo, Columbia University. Complete Solution

NURS 111 Premature Infant Exam. Meet the Client: Jamie Fargo, Columbia University. Complete Solution.Premature Infant: Meet the Client: Jamie Fargo Jamie Fargo, a 17-year-old-student, is pregnant. She has not told her family about the pregnancy and has not sought prenatal care. One evening she tells her Mom that she is feeling "really bad" with abdominal cramps, so her mother takes her to the emergency center. After examination by a healthcare provider, Jamie is found to be 30 weeks pregnant and in active labor. Family Care During Labor 1. Which approach should the nurse use in sharing this information with Jamie and her mother? A) Talk with Jamie's mother first and inform her of the situation. INCORRECT The mother is unaware of the pregnancy and Jamie should be present due to confidentially issues. B) Approach Jamie and her mother together and discuss the findings. INCORRECT The mother is unaware of the pregnancy and Jamie should be given the choice to decide if she wants to tell her mother or have the nurse tell Jamie's mother. C) Discuss the situation with Jamie first and then talk with her mother. CORRECT Although Jamie is a minor and her mother should be involved, approaching Jamie first gives the nurse an opportunity to gather additional information and provide needed support. D) Ask the social worker for advice on which approach should be taken. INCORRECT A social worker may become involved, but is not needed when the initial health information is communicated. Correct Answer(s): C Jamie is admitted to the Birthing Center with contractions every 3 to 4 minutes, ­1 station, 50% effaced and 6 cm cervical dilation. After starting an IV, the nurse administers betamethasone sodium phosphate (Celestone Phosphate) 2 ml IM. Jamie asks the nurse why she is receiving the betamethasone. 2. Which response should the nurse give Jamie? A) The inflammation process present will be diminished. INCORRECT Although an inflammatory process may be present, this medication is not given for that purpose. B) Infection present during preterm labor will be eliminated. INCORRECT There may be an infection present, but this medication is not given as an antiinfective. C) The premature infant's lungs will function more maturely. CORRECT Betamethasone is given during preterm labor to stimulate lecithin production and to prevent respiratory distress syndrome (RDS). It takes approximately 24 to 48 hours for the medication to be effective in preventing RDS. D) Uterine contractions will diminish in frequency and intensity. INCORRECT This medication is not given as a tocolytic. Correct Answer(s): C A nursing student is working with the nurse caring for Jamie. 3. In anticipation of a premature birth, what should the nurse instruct the student to do first? A) Cover the scales with a warm blanket. INCORRECT This should be done prior to the use of the scales to prevent cooling of the blanket. B) Prepare equipment for resuscitation. CORRECT Preparation of resuscitation equipment is critical in anticipating a preterm birth. At 30 weeks gestation, fetal lung immaturity, poor development of pulmonary vasculature, and possible delayed closure of the ductus arteriosus related to hypoxia are critical factors related to the development of neonatal respiratory distress. C) Draw up the phytonadione (AquaMEPHYTON). INCORRECT This should be done prior to its administration and within 1 hour of birth. D) Have the opthalmic erythomycin ointment (Ilosone) available. INCORRECT This should be done, but can be delayed until transfer of the infant to the nursery. Correct Answer(s): B Infant Care at Birth Labor continues for 12 hours and a baby boy is delivered vaginally. The nurse places the infant under a radiant warmer and dries him quickly. 4. What is the rationale for this nursing intervention? A) Prepare for resuscitation. INCORRECT Whether or not resuscitation is needed, the nurse should place the infant under the radiant warmer for another reason. B) Prevent further heat loss. CORRECT Premature infants have a high ratio of body surface to body weight and very little subcutaneous fat, which predisposes the infant to heat loss by convection, conduction, radiation, and evaporation. The nurse should dry his skin and place him under a radiant warmer to decrease heat loss. C) Make the infant comfortable. INCORRECT Although exposure stimulates sensory discomfort, another physiological mechanism supports this action. D) Remove vernix and lanugo. INCORRECT While drying the infant may remove some of the vernix and lanugo that is not why the infant is placed under the radiant warmer.