The nurse is planning care for a low birth weight newborn. Which is an appropriate nursing intervention to promote adequate oxygenation?

Correct Answer: C

Rationale: Maintaining a neutral thermal environment is an appropriate nursing intervention to promote adequate oxygenation in a low birth weight newborn. Newborns, especially those with low birth weight, have limited capacity to regulate their body temperature. Keeping the baby warm helps prevent cold stress, which can lead to increased metabolic demands and oxygen consumption. By maintaining a neutral thermal environment, the newborn's energy can be directed towards growth and development, rather than compensating for temperature fluctuations. This intervention helps optimize oxygenation and overall well-being of the low birth weight newborn. The other options (A, B, D) do not directly address the need for adequate oxygenation in a low birth weight newborn.

Correct Answer: B

Rationale: The first molar typically erupts at 6 years.

Correct Answer: C

Rationale: Peripheral edema is a common clinical manifestation of systemic venous congestion that can occur with heart failure. In heart failure, the heart is unable to pump effectively, leading to a backup of blood in the veins. This increased pressure in the veins causes fluid to leak out into the surrounding tissues, resulting in swelling or edema, most commonly in the lower extremities. Tachypnea (rapid breathing) and tachycardia (fast heart rate) are more associated with the compensatory mechanisms of the body to try to maintain cardiac output and oxygenation. Pale, cool extremities are more indicative of poor peripheral perfusion, which can occur with severe heart failure but are not the typical manifestations of systemic venous congestion.

Correct Answer: C

Rationale: Chronic respiratory acidosis is a condition where there is an excess of carbon dioxide (CO2) in the blood due to inadequate exhalation of CO2. This typically occurs as a result of hypoventilation, which is characterized by breathing at an abnormally slow rate or shallow depth. In patients with long-standing lung disease, the ability to effectively exchange gases in the lungs is compromised, leading to a buildup of CO2 in the bloodstream and subsequent respiratory acidosis. Hyperventilation, on the other hand, would result in a decrease in CO2 levels in the blood, while the loss of acid or base by the kidneys is related to metabolic acidosis or alkalosis, not respiratory acidosis. Therefore, in this case, the primary problem causing chronic respiratory acidosis is hypoventilation.

Correct Answer: B

Rationale: Strabismus, or misalignment of the eyes, is a common condition in newborns due to the lack of binocularity. Binocularity refers to the ability of both eyes to focus simultaneously on a single point, which is not fully developed in newborns. As a result, it is normal for a newborn's eyes to appear misaligned at times. This lack of coordination between the eyes typically resolves as the infant's visual system matures and they develop the ability to focus both eyes together. Therefore, the presence of strabismus in a newborn is usually considered a normal finding related to the immature visual development rather than a sign of pathology such as congenital cataracts, absence of red reflex, or pupil reactivity issues.