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 C
Explanation
The mother is Rh negative and the father is Rh positive. Hemolytic disease of the newborn (HDN) is caused by an incompatibility between the blood types of the mother and fetus. Specifically, it occurs when a Rh-negative mother carries a fetus who is Rh-positive, and the mother's immune system produces antibodies against the Rh antigen on the fetal red blood cells. These antibodies can cross the placenta and destroy the fetal red blood cells, leading to anemia and other complications in the newborn. If a mother has Rhnegative blood, it means that she lacks the Rh antigen on her red blood cells. If the father has Rh-positive blood, there is a chance that the fetus will inherit the Rh antigen from the father. If the fetal Rh-positive blood enters the mother's bloodstream during pregnancy or delivery, the mother's immune system can produce antibodies against the Rh antigen, causing HDN in subsequent pregnancies with Rh-positive fetuses.
Correct Answer is B
Explanation
A. A respiratory rate of 55 breaths per minute is within the normal range for a full-term newborn, which is generally between 30 and 60 breaths per minute.
B. A heart rate of 72 beats per minute is significantly lower than the normal range for a newborn. Normal heart rates for newborns typically range from 120 to 160 beats per minute. A heart rate this low could indicate bradycardia, which requires immediate assessment and intervention.
C. A temperature 36.5° C (97.7° F) is slightly below the normal range for newborns, which is typically between 36.6°C to 37.2°C (97.9°F to 99.0°F). However, it may not be immediately concerning unless it is part of a pattern or accompanied by other symptoms.
D. A blood pressure reading of 80/50 mm Hg is within the expected range for a full-term newborn, where typical values are approximately 60-80 mm Hg for systolic and 40-50 mm Hg for diastolic.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.