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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Correct Answer is D

Explanation

Rationale:

A. "Go to bed at least 2 hours earlier than usual.": Going to bed earlier may increase total sleep time, but it does not directly address the cause of nighttime awakening—frequent urination. Earlier bedtime alone is unlikely to improve the client’s quality of sleep.

B. "Have a snack before bedtime.": A bedtime snack may help prevent nausea or maintain blood sugar levels but does not reduce nighttime urinary frequency. In some cases, it might lead to increased fluid intake, potentially worsening nocturia.

C. "Drink a cup of chamomile tea at bedtime.": While chamomile may promote relaxation, it is also a fluid, which can increase bladder activity during the night. Encouraging tea before bed may worsen the client's urinary frequency and sleep disruption.

D. "Take regular rest periods during the day.": Taking rest periods throughout the day can help reduce overall fatigue and minimize sleep disruption caused by nocturia. Resting during the day compensates for nighttime interruptions and supports maternal well-being in early pregnancy.

A. The restraint tie strap is tied into a knot. B. The restraint is attached to the side rails of the bed. C. The skin under the restraint is cool and has changed color. D. The nurse can insert two fingers under the restraint.

Correct Answer is D

Explanation

Rationale:

A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.

B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.

C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.

D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.

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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?

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