A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1° C (97° F). Which of the following actions should the nurse take?
Apply a cap to the newborn's head.
Give the newborn a warm bath.
Reposition the newborn.
Obtain an oxygen saturation level.
The Correct Answer is A
A. Apply a cap to the newborn's head: This is an appropriate intervention to conserve heat in a mildly hypothermic newborn. It is a standard practice to maintain thermal neutrality, especially in the first hours after birth.
B. Give the newborn a warm bath: Bathing is not appropriate for a newborn with a low temperature. Bathing could worsen heat loss and further lower the newborn's body temperature.
C. Reposition the newborn: While repositioning may improve comfort or support effective respiration, it does not directly address the low temperature.
D. Obtain an oxygen saturation level: The respiratory rate (50/min) and heart rate (130/min) are within the normal range for a newborn. Unless other signs of respiratory distress or cyanosis are present, this action is unnecessary.
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Related Questions
Correct Answer is C
Explanation
A. Right upper quadrant: This is not the correct location for hearing the fetal heart rate in the LOA position, as it is on the opposite side and higher than expected.
B. Left upper quadrant: The fetal heart rate in the LOA position is heard below, not above, the maternal umbilicus.
C. Left lower quadrant: The PMI of the fetal heart rate is best heard in the left lower quadrant when the fetus is in the left occipitoanterior position, as the fetal back (closest to the heart) is located on the left side and positioned anteriorly.
D. Right lower quadrant: This site is appropriate for a right occipitoanterior (ROA) fetal position, not LOA.
Correct Answer is ["A","C"]
Explanation
A. Labor induction with oxytocin: The use of oxytocin for labor induction can increase the risk of postpartum hemorrhage due to uterine atony, where the uterus fails to contract effectively after delivery.
B. History of human papillomavirus: A history of human papillomavirus does not directly increase the risk of postpartum hemorrhage.
C. Vacuum-assisted delivery: Instrumental deliveries, such as those using a vacuum, are associated with an increased risk of trauma to the birth canal, which can contribute to postpartum hemorrhage.
D. Newborn weight 2.948 kg (6 lb 8 oz): A newborn weight of 2.948 kg is within the normal range and does not by itself increase the risk of postpartum hemorrhage. Larger babies (macrosomia) are more commonly associated with an increased risk.
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