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A nurse is caring for a newborn who was just delivered at 35 weeks of gestation.

Click to highlight the action(s) the nurse should take to address each assessment finding. To deselect a nursing action, click the nursing action again

Assessment Findings

Nursing Actions

Body Temperature

swaddle the newborn in a blanket

dry the newborn

monitor the newborn's vital signs

place the newborn under radiant warmer

Respiratory Status

administer free-flow oxygen

clear airway using bulb suction

initiate chest compressions

place the newborn in prone position

swaddle the newborn in a blanket

dry the newborn

monitor the newborn's vital signs

place the newborn under radiant warmer

administer free-flow oxygen

clear airway using bulb suction

initiate chest compressions

place the newborn in prone position

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Rationale for Correct Choices

• Swaddle the newborn in a blanket: Swaddling helps reduce heat loss through convection and evaporation, which is essential for a preterm newborn who has limited brown fat and poor thermoregulation. Maintaining warmth helps stabilize respiratory effort and metabolic demand. It is appropriate because the newborn’s temperature is below normal and continues to trend low.

• Dry the newborn: Drying reduces evaporative heat loss, which is a major risk immediately after birth, especially for late-preterm infants. Removing moisture from the skin supports temperature stabilization and reduces metabolic stress. This action is essential when temperatures remain below 36.5° C.

• Monitor the newborn’s vital signs: Frequent monitoring helps detect changes in temperature, heart rate, and respiratory drive, all of which can fluctuate rapidly in late-preterm newborns. Continuous monitoring allows the nurse to evaluate whether interventions for temperature and oxygenation are effective.

• Place the newborn under a radiant warmer: A radiant warmer provides controlled heat to support thermoregulation in preterm newborns who cannot maintain temperature independently. With temperatures at 36° C and 36.4° C, thermoregulation support is indicated to prevent cold stress. Radiant warming also helps stabilize oxygenation and metabolic rate.

• Administer free-flow oxygen: The newborn’s oxygen saturation is low at 90–91% on room air, indicating mild respiratory compromise. Providing free-flow oxygen improves oxygenation without requiring invasive airway management. This is appropriate for a newborn with increased respiratory effort but stable heart rate.

• Clear airway using bulb suction: Bulb suctioning is appropriate if secretions contribute to increased respiratory rate or difficulty maintaining saturation. Clearing the airway helps remove mucus that may impair airflow in preterm newborns. It supports spontaneous breathing and improves oxygenation.

Rationale for Incorrect Choices

• Initiate chest compressions: Chest compressions are only indicated when the newborn’s heart rate is below 60/min after at least 30 seconds of effective ventilation. This newborn’s heart rate is between 124–144/min, which is well above the threshold for resuscitation. Chest compressions are unnecessary and inappropriate for this clinical status.

• Place the newborn in prone position: Prone positioning is not recommended for routine stabilization and can compromise airway patency in a newborn requiring continuous monitoring. Supine or side-lying positioning reduces risk of airway obstruction and allows optimal chest expansion. Prone positioning increases risk for respiratory compromise in the acute period.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Perform bimanual fundal massage: Excessive vaginal bleeding postpartum often indicates uterine atony. Performing a bimanual fundal massage helps stimulate uterine contraction, which can reduce hemorrhage. This is a primary and immediate intervention in postpartum bleeding management.

B. Weigh perineal pads: Weighing pads helps quantify blood loss but does not actively stop hemorrhage. While important for assessment and documentation, it is not the first action when the client is actively bleeding.

C. Initiate oxygen at 2 L/min via nasal cannula: Administering oxygen may support tissue oxygenation but does not address the underlying cause of postpartum hemorrhage. Oxygen is supportive care and should not replace interventions to control bleeding.

D. Administer terbutaline: Terbutaline is a uterine relaxant used to treat preterm labor, which would worsen postpartum bleeding by inhibiting uterine contraction. It is contraindicated in cases of active postpartum hemorrhage.

A. Keep all four of the side rails raised on the client's bed. B. Check the client every 4 hr to evaluate their need to use the restroom. C. Instruct the client to stand in place when beginning ambulation. D. Maintain the client's bed at the nurse's waist level.

Correct Answer is C

Explanation

A. Keep all four of the side rails raised on the client's bed: Raising all four side rails can increase the risk of injury if the client attempts to climb over them. Full side rails are not a recommended fall-prevention strategy for clients with orthostatic hypotension.

B. Check the client every 4 hr to evaluate their need to use the restroom: Checking every 4 hours may not be frequent enough to prevent falls related to sudden episodes of dizziness or urgency. More proactive measures, such as assisting with ambulation, are safer for clients at risk.

C. Instruct the client to stand in place when beginning ambulation: Having the client stand in place for a few moments allows blood pressure to stabilize before walking, reducing the risk of dizziness and falls caused by orthostatic hypotension. This is a key intervention for fall prevention in at-risk clients.

D. Maintain the client's bed at the nurse's waist level: The bed height should be adjusted to facilitate safe transfers, typically at the level that allows feet to touch the floor and promotes stability. Keeping the bed at the nurse's waist level does not specifically prevent falls due to orthostatic hypotension.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is at risk for a fall because of orthostatic hypotension. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse administered 400 mg of ibuprofen to a client 2 hr ago to treat pain following a biopsy. The client is crying and states. "It really still hurts a lot. Which of the following actions should the nurse take?

A nurse is reviewing laboratory results for a client who has heart failure and notes a serum potassium level of 5.2 mEq/L (3.5 to 5.0 mEq/L). Which of the following medications should the nurse withheld?

A nurse is developing a plan of care for a client who has a gambling disorder. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who is 24 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

A nurse is reviewing laboratory findings for a client who is to receive a dose of enoxaparin. For which of the following laboratory values should the nurse withhold the dose and notify the provider?

A nurse is preparing a staff training on fall prevention for clients who have moderate dementia. Which of the following strategies should the nurse include?

A nurse is caring for a client who is postoperative and has a chest tube drainage system. For which of the following findings should the nurse notify the provider?

A nurse is providing teaching about self-care to a client who is primigravid and at 9 weeks of gestation. Which of the following statements should the nurse include?