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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. "You should have a sputum examination every 4 weeks.": Monthly sputum samples are necessary to monitor treatment effectiveness and determine when the client is no longer infectious. Clients typically need three consecutive negative sputum cultures to be considered non-contagious.

B. "You should obtain a chest x-ray every 3 months.": Chest x-rays are not routinely used for frequent follow-up during treatment. They may be used at diagnosis or treatment completion, but monthly sputum cultures are more reliable for monitoring active infection.

C. "You should schedule a tuberculin skin test every 6 months.": A tuberculin skin test is not useful for clients with active TB or for monitoring treatment response. Once a person has tested positive, repeat testing is not recommended due to persistent reactivity.

D. "You should stop taking your antituberculin medication after 2 weeks.": TB treatment requires a prolonged course typically 6 to 12 months. Stopping medication after 2 weeks increases the risk of treatment failure, relapse, and drug resistance, even if symptoms improve.

A. past medical history B. illusions C. change in orientation D. hallucinations

Correct Answer is ["C","D"]

Explanation

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.

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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?

Nursing Test Bank

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A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client in the intensive care unit (ICU) Exhibits The nurse should identify which of the following client's conditions can indicate the development of delirium.

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