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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A respiratory rate of 22/min would be abnormally low for a newborn. The expected reference range for newborns is around 30-60 breaths per minute.
Choice B rationale:
A respiratory rate of 100/min would be abnormally high for a newborn. Such a high respiratory rate may indicate respiratory distress or other underlying issues and requires further evaluation.
Choice C rationale:
A respiratory rate of 48/min falls within the expected reference range for a newborn, which is around 30-60 breaths per minute. This rate suggests that the newborn's respiratory system is functioning within the normal range.
Choice D rationale:
A respiratory rate of 110/min would be abnormally high for a newborn. As mentioned earlier, the expected reference range for newborns is around 30-60 breaths per minute, making this rate concerning and necessitating further assessment.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Drying the baby thoroughly is not directly related to assessing the successful transition of the respiratory system. It is essential for warmth and comfort but does not provide specific information about the respiratory system.
Choice B rationale:
Suctioning the mouth and nose with a bulb syringe to clear mucus is important to ensure the airways are clear and the newborn can breathe effectively. This action helps assess the airway patency and successful initiation of breathing.
Choice C rationale:
Observing the chest and abdomen is crucial to assess the respiratory effort and symmetry. Normal chest movements and equal rise and fall of the abdomen indicate a successful transition of the respiratory system.
Choice D rationale:
Counting the number of respirations per minute is essential to determine if the respiratory rate falls within the expected reference range (around 30-60 breaths per minute for a newborn) and if there are any irregularities.
Choice E rationale:
Observing the color of the mucous membranes is important as cyanosis (blue discoloration) may indicate inadequate oxygenation. Pink mucous membranes are a positive sign, indicating a successful transition of the respiratory system.
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