Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?

Correct Answer: D

Rationale: The correct answer is D: Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers. Rationale: 1. Teaching parents signs of overstimulation empowers them to recognize and respond to their infant's cues effectively. 2. Parents can then modify the environment or interactions to reduce overstimulation, hence decreasing oxygen use. 3. This intervention promotes parental involvement in the care of the preterm infant, fostering a supportive and nurturing environment. 4. By educating parents, the nursing staff can work collaboratively with families to optimize the infant's care and well-being. Summary: A: Grouping care activities may help with rest but does not directly address overstimulation and increased oxygen use. B: Keeping charts on top of the incubator is irrelevant to addressing overstimulation. C: Providing a soft report does not directly address overstimulation or involve parents in recognizing signs.

Correct Answer: D

Rationale: The correct answer is D because preventing hypoglycemia is crucial for Small for Gestational Age (SGA) newborns due to their decreased glycogen stores. Early and frequent feedings help maintain stable blood sugar levels. Option A, promoting bonding, is important for all newborns but not particularly crucial for SGA babies. Option B, preventing dehydration, is essential for all newborns but not specific to SGA. Option C, observing for respiratory distress syndrome, is important but not the most critical concern for SGA newborns.

Correct Answer: B

Rationale: The correct answer is B because weight gain is a direct indicator of nutritional status. A weight gain of 40 g/day may indicate inadequate caloric intake for an SGA (small for gestational age) infant, necessitating additional calories. A: Hematocrit level might indicate dehydration or polycythemia, not necessarily inadequate caloric intake. C: The volume of intake alone does not indicate the adequacy of caloric intake; concentration and composition of the feed are also essential. D: Temperature measurements are not directly related to the need for additional calories in an SGA infant.

Correct Answer: B

Rationale: The correct answer is B: VLBW (Very Low Birth Weight). This classification is based on the infant weighing less than 1500 g at birth, which applies to this scenario as the infant weighs 1200 g. VLBW infants are at higher risk for complications due to their low weight and prematurity. A: SG (Small for Gestational Age) is incorrect because it refers to infants who are below the 10th percentile for weight at a specific gestational age, not based solely on weight. C: ELBW (Extremely Low Birth Weight) is incorrect as it typically refers to infants weighing less than 1000 g at birth, which is lower than the infant in this scenario. D: Low birth weight at term is incorrect as it does not accurately classify a premature infant like the one in the question.

Correct Answer: C

Rationale: The correct answer is C: Fluid volume deficit related to phototherapy treatment. Priority nursing diagnoses are based on ABCs (Airway, Breathing, Circulation). Fluid volume deficit can result from phototherapy due to increased insensible water loss. This can lead to dehydration and electrolyte imbalances, impacting circulation and overall well-being. Hypothermia (choice A) is important but not the priority in this case. Impaired skin integrity (choice B) is a potential issue but not as critical as fluid volume deficit. Knowledge deficit (choice D) is important for parental education but not an immediate concern compared to fluid balance in the newborn.