A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?

The newborn's temperature control mechanism is immature.

Heat increases the flow of oxygen to the newborn's extremities.

The newborn has a small body surface for his weight.

Heat facilitates the drainage of mucus for a premature newborn.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Placing the newborn in an incubator is essential because the newborn's temperature control mechanism is immature. Premature infants have an underdeveloped thermoregulatory system, making them susceptible to heat loss and cold stress. An incubator provides a controlled, warm environment to maintain the newborn's body temperature within the normal range (around 36.5°C to 37.5°C or 97.7°F to 99.5°F).

Choice B rationale:

Heat increasing the flow of oxygen to the newborn's extremities is not a valid reason for placing the newborn in an incubator. Oxygenation is primarily influenced by respiratory and circulatory mechanisms, not external heat.

Choice C rationale:

The newborn's small body surface area for his weight is not directly related to the need for an incubator. Premature infants have a higher surface area to weight ratio, making them more prone to heat loss, but this is not the primary reason for using an incubator.

Choice D rationale:

Heat facilitating the drainage of mucus is not a reason for placing the newborn in an incubator. Proper positioning and suctioning are used to manage mucus in premature infants, but incubators are primarily for temperature regulation.

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Correct Answer is C

Explanation

Choice A rationale:

Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.

Choice B rationale:

Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.

Choice C rationale:

Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.

Choice D rationale:

Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.

A. Activate respiratory arrest procedures. B. Request an order for supplemental oxygen. C. Continue routine monitoring. D. Report the observation to the charge nurse immediately.

Correct Answer is C

Explanation

Choice A rationale:

Activating respiratory arrest procedures is not necessary in this situation. The newborn's respiratory rate, although slightly elevated, does not indicate respiratory arrest. Instead, such procedures are reserved for situations where the newborn has stopped breathing or is in acute respiratory distress.

Choice B rationale:

Requesting an order for supplemental oxygen may be premature. The newborn's respiration rate of 44/min, although shallow with periods of apnea, is still within the normal range for a newborn. Providing supplemental oxygen should be considered when the newborn is showing signs of significant respiratory distress or if oxygen saturation levels are low.

Choice C rationale:

The most appropriate action in this scenario is to continue routine monitoring of the newborn's respiratory rate and overall condition. Newborns often exhibit irregular breathing patterns, including periods of apnea, especially in the first few hours after birth. As long as the newborn's color, heart rate, and overall appearance are stable, routine monitoring is appropriate.

Choice D rationale:

There is no need to report the observation to the charge nurse immediately, as the newborn's respiratory rate and pattern fall within the expected range for a 12-hour-old newborn.

Reporting should be considered when there are significant deviations from the norm or if the newborn's condition deteriorates.

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A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?

Nursing Test Bank

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A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle-feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

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Explanation

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