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 A

Explanation

Rationale:

A. "Perform sponge baths until the baby's umbilical cord falls off.": This is the appropriate instruction because keeping the umbilical stump dry reduces the risk of infection and promotes natural detachment. Sponge baths help prevent water from soaking the cord area until it fully heals and separates.

B. "Use an alkaline soap to bathe the baby.": Alkaline soaps can irritate a newborn’s sensitive skin by disrupting the natural acidic pH balance. Mild, pH-neutral or hypoallergenic baby cleansers are recommended to maintain skin integrity.

C. "Ensure the bath water is at least 96 degrees Fahrenheit.": Bath water should be warm, around 98.6°F (37°C), which is close to body temperature. Setting a minimum like 96°F may be too low and uncomfortable, while overheating the water poses a burn risk.

D. "Apply talcum powder daily after bathing in order to prevent diaper rash.": Talcum powder is not recommended due to the risk of respiratory irritation if inhaled. Preventing diaper rash is better achieved through frequent diaper changes and the use of barrier creams.

A. Cleanse the perineum with 0.9% sodium chloride after bowel movements B. Obtain serial blood cultures. C. Insert and maintain an indwelling urinary catheter. D. Encourage the use of a sitz bath twice a day,

Correct Answer is B

Explanation

Rationale:

A. Cleanse the perineum with 0.9% sodium chloride after bowel movements: While perineal hygiene is important postpartum, cleansing with normal saline is more routine care and does not specifically target endometritis management.

B. Obtain serial blood cultures: Endometritis is a uterine infection that can lead to bacteremia or sepsis. Serial blood cultures help identify the causative organism and guide antibiotic therapy.

C. Insert and maintain an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not routinely used unless there is urinary retention or other specific indications.

D. Encourage the use of a sitz bath twice a day: Sitz baths promote perineal comfort and hygiene but do not directly treat uterine infections like endometritis. They may be recommended for perineal pain but are not primary treatment for endometritis.

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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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