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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client's cervical dilation and effacement indicate that she is in active labor and progressing rapidly. Because the client is already 8 cm dilated and has been in labor for only 1 hour, the nurse should recognize that the client is at risk for a rapid delivery, which can increase the risk of postpartum hemorrhage. The other options listed are not associated with cervical dilation and effacement during active labor.
Correct Answer is D
Explanation
A. An HbA1C level of 6% is within the target range for a pregnant woman with type 1 diabetes, indicating good glycemic control. Therefore, it does not need to be reported to the provider.
B. Platelet levels of 170,000/mm³ fall within the normal range (150,000–450,000/mm³) and do not indicate a need for concern.
C. A hematocrit (Hct) of 34% is slightly low, but mild anemia is common during pregnancy due to increased plasma volume. This level does not usually require immediate intervention.
D. A blood urea nitrogen (BUN) level of 25 mg/dL is elevated (normal range 7–20 mg/dL) and may indicate renal impairment, which is a concern in a pregnant client with type 1 diabetes. This finding should be reported to the provider as it can signal potential kidney issues that need to be addressed.
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