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 D
Explanation
The nurse manager should instruct newly hired nurses to place newborn bassinets at least 3 feet apart to reduce the risk of infection transmission in the nursery. Allowing parents to enter the nursery while wearing a mask is not a recommended infection control procedure. Placing the newborn's foot on a sterile field during a heel stick is a standard precaution to reduce the risk of infection. Airborne precautions are not required in a newborn nursery unless the infant has a suspected airborne infectious disease
Correct Answer is B
Explanation
administer a bolus infusion of lactated Ringer's. Maternal hypotension is a common complication of epidural anesthesia. A bolus infusion of lactated Ringer's is an appropriate intervention for maternal hypotension due to the increased volume and pressure it provides, which can help to raise the client's blood pressure. The knee-chest position is not an appropriate intervention for maternal hypotension as it can cause a decrease in venous return to the heart. Terbutaline is a tocolytic medication used to stop premature labor, and it is not indicated for maternal hypotension. Oxygen via a nonrebreather face mask at 2 L/min is not an appropriate intervention for maternal hypotension as it does not address the underlying cause of the hypotension.
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