A nurse is contributing to the plan of care for a newborn who has a temperature of 36.4° C (97.5° F) at 1 hr after birth. Which of the following interventions should the nurse include?
Dress the newborn in a warm gown when placing them next to the parent's skin.
Delay the newborn's feedings until their temperature is stabilized.
Postpone the newborn's initial bath
Place the swaddled newborn under a radiant warmer.
The Correct Answer is C
Rationale:
A. Dress the newborn in a warm gown when placing them next to the parent's skin: Skin-to-skin contact, not clothing layers, is the priority for thermoregulation in the first hours after birth. A warm gown may interfere with skin contact and reduce the effectiveness of heat transfer from parent to newborn.
B. Delay the newborn's feedings until their temperature is stabilized: Early feeding is encouraged for newborns to promote bonding, glucose stabilization, and warmth. Feeding should not be delayed, as it can help the baby generate heat through metabolism.
C. Postpone the newborn's initial bath: A newborn’s bath should be delayed until their temperature is stable to prevent further heat loss. Bathing can cause evaporation-related cooling, which may worsen mild hypothermia in a newborn during the early hours of life.
D. Place the swaddled newborn under a radiant warmer: Swaddling under a radiant warmer interferes with direct heat transfer. The newborn should be unclothed (except for a diaper) under the warmer to ensure effective warming through radiation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Use touch to convey acceptance: Using touch with clients who are actively hallucinating can be misinterpreted and may provoke fear or aggression. Maintaining a safe physical distance and using verbal reassurance is more appropriate during episodes of hallucination.
B. Avoid attempting to distract the client away from the hallucination: Distraction techniques are often helpful in managing hallucinations. Encouraging the client to engage in a different activity or conversation can help shift their focus away from distressing perceptual disturbances.
C. Encourage group activities: Group settings may increase anxiety or overstimulation for a client who is actively hallucinating. Individualized, low-stimulation environments are more therapeutic during acute symptoms.
D. Provide low lighting in the client's room: A calm, low-stimulation environment including dim lighting can reduce sensory overload and help the client feel more secure. Low lighting may also help minimize misinterpretation of visual stimuli that could feed into hallucinations.
Correct Answer is D
Explanation
Rationale:
A. Open the side flap of the sterile kit, allowing it to lie flat on the work surface: This step comes later in the process of opening a sterile field. Side flaps should be opened after the top (farthest) flap to prevent reaching over the sterile field and contaminating it.
B. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface: Opening the closest flap first risks contaminating the sterile field by reaching over it. This flap should be opened last, after the top and side flaps are already secured.
C. Apply sterile gloves: Sterile gloves are applied after the sterile field is prepared and all supplies are organized within the sterile area. Putting them on too early may lead to contamination during field setup.
D. Open the outermost flap of the sterile kit away from the nurse's body: The first step in establishing a sterile field is to open the flap away from the body. This minimizes contamination by preventing the nurse from leaning over the sterile surface.
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