A nurse is caring for a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6" F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?
Dry and stimulate newborn with towel.
Place a hat on the newborn's head.
Maintain the delivery room temperature at 20° C (68° F)
Place a blanket on top of maternal dent and newborn.
The Correct Answer is C
A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.
B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.
C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.
D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Have you had any health concerns during your pregnancy?"
While it's important to assess the client's overall health and pregnancy history, this question doesn't directly address the current concern of possible labor and does not immediately help assess the client's status for labor evaluation. The focus should be on signs of labor or complications at this point.
B) "Do you have a support person present?"
Although this is a helpful question to ask in preparation for labor, it doesn't provide the necessary information needed to assess whether the client is in labor. The priority at this stage is determining if the client is in labor or experiencing any complications, such as rupture of membranes.
C) "Have you noticed any fluid leaking from your vagina?"
This is the most important question to ask next. If the client has ruptured membranes (i.e., water breaking), it is important to assess the timing and nature of the fluid leakage, as it would indicate the need for immediate evaluation at the hospital. Rupture of membranes requires monitoring for infection and should prompt the client to come in for assessment regardless of the frequency or intensity of contractions.
D) "When was your last prenatal visit?"
While it is helpful to know when the client had their last prenatal visit, this question does not directly address the issue of possible labor. The priority is to determine if the client is in labor, whether their membranes have ruptured, or if there are any other complications such as bleeding or abnormal fetal movement. The question about fluid leakage is more immediate and relevant to their current condition.
Correct Answer is ["B","E"]
Explanation
A) Fusion of labia in female genitalia:
Fusion of the labia in a female newborn is not an expected finding. This could indicate a condition such as labial adhesion or an abnormality in the development of the genitalia. Normally, the labia in a female newborn are separated. Any signs of fusion would require further evaluation by the healthcare provider.
B) Erythema toxicum on newborn's skin:
Erythema toxicum is a common and expected finding in newborns, usually appearing within the first 2–3 days of life. It consists of small, red papules or pustules on a red base, often described as a "flea-bitten" appearance. This rash is benign and resolves on its own within a few days to weeks. It is not associated with any infection or underlying health issues.
C) Hypospadias is noted in the male newborn:
Hypospadias, a condition where the urethral opening is located on the underside of the penis rather than at the tip, is not an expected finding in all newborn males. While it occurs in a small percentage of male infants, it is a congenital anomaly that would require further assessment and possibly surgical correction. It is not considered a normal finding in a newborn.
D) Presence of syndactyly in extremities:
Syndactyly, the condition where two or more fingers or toes are fused together, is not a normal finding in newborns. While it is a congenital anomaly that can occur in some infants, it is not expected and requires further evaluation and possibly surgical intervention depending on the severity.
E) Negative Ortolani sign:
A negative Ortolani sign is an expected and normal finding in a newborn. The Ortolani maneuver is used to assess for hip dislocation, and a negative result indicates that the hip is stable and not dislocated. If the Ortolani sign were positive, it would suggest the presence of a developmental hip dysplasia, which would require further diagnostic evaluation. A negative sign is considered typical and reassuring.
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