N4 CH 17 High-Risk Neonatal Nursing Care questions with correct answers

The nurse in NICU is assessing a neonate delivered at 32 weeks gestation. Which pathophysiological manifestation is the nurse's greatest concern? 1. Absent or weak reflexes 2. Presence of a heart murmur 3. Apnea 20 seconds or longer 4. Low hemoglobin lab level CORRECT ANSWER ANS: 3 3. This is correct. Apnea for 20 seconds or longer is the nurse's greatest concern. Even though this is expected in premature neonates, the nurse will still focus on ABCs. The labor and delivery nurse is present for the delivery of a premature neonate. Which action by the nurse is most important? 1. Stabilize and transfer neonate to NICU. 2. Review pregnancy history for risk factors. 3. Maintain fluid and electrolyte balance. 4. Provide a neutral temperature environment. CORRECT ANSWER ANS: 4 4. This is correct. When attending a premature birth, the most important nursing action is to provide a neutral temperature environment (NTE). The premature neonate is at risk for increased loss of heat because of diminished amounts of subcutaneous fat. The nurse needs to take measures to prevent cold stress, which can be fatal. he nurse is providing care for a p