A nurse is performing a head-to-toe assessment on a newborn. Which of the following actions should the nurse take to prevent heat loss through conduction?
Conduct the assessment before drying the newborn.
Check the newborn's rectal temperature every hr.
Place the newborn in an open crib for the initial assessment.
Cover scale with warm blankets when weighing the newborn.
The Correct Answer is D
Rationale:
A. Conduct the assessment before drying the newborn: Performing the assessment before drying exposes the newborn’s wet skin to cooler air and surfaces, increasing heat loss through evaporation, not conduction. The newborn should always be thoroughly dried immediately after birth to conserve body heat.
B. Check the newborn's rectal temperature every hr: Frequent temperature monitoring does not prevent heat loss; it only identifies hypothermia after it occurs. Additionally, rectal temperature measurement may cause mucosal injury and is not routinely recommended for newborns.
C. Place the newborn in an open crib for the initial assessment: Placing the newborn in an open crib exposes the infant to cooler air and surfaces, increasing heat loss through convection and conduction. The initial assessment should occur under a radiant warmer to maintain thermal stability.
D. Cover scale with warm blankets when weighing the newborn: Covering the scale prevents conduction heat loss, which occurs when the newborn’s skin comes into contact with cold surfaces. Using a warm blanket or pad ensures the infant’s body heat is preserved during weighing or handling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Obtain a prescription to refer the client to physical therapy: A referral to physical therapy is appropriate because therapists can design individualized exercises to improve balance, coordination, and strength. This intervention promotes safe mobility, enhances independence, and reduces fall risk for clients with post-stroke weakness.
B. Instruct the client to wear sandals when ambulating: Sandals do not provide adequate foot support or traction and increase the risk of tripping or falling. Clients with right-sided weakness should wear well-fitting, non-skid shoes to ensure safety and stability during ambulation.
C. Encourage the client to dim the lights in hallways: Poor lighting impairs visibility and increases the risk of falls, especially for clients with weakness or gait instability. Adequate illumination in hallways and pathways is essential for safety during ambulation.
D. Instruct the client to place throw rugs on bathroom floors: Throw rugs are a major fall hazard due to their tendency to slip or bunch up. The nurse should advise removing rugs or securing them with non-slip backing to create a safe, stable walking environment.
Correct Answer is D
Explanation
Rationale:
A. Call in additional medical-surgical unit nursing care staff: Calling in staff may be part of the overall disaster plan but is typically coordinated by administration or the incident command team, not by individual unit nurses.
B. Act as a liaison between the facility and the media: Communication with the media is the responsibility of the facility’s public information officer or designated spokesperson, not bedside nurses.
C. Determine the medical needs of incoming clients through the emergency department: Triage and assessment of incoming clients occur in the emergency department by the triage nurse or emergency staff, not on the medical-surgical unit.
D. Recommend to the provider specific acute care clients for discharge: In a mass casualty event, medical-surgical nurses help identify stable clients who can be safely discharged or transferred to make room for incoming critical clients. This is an essential role in surge capacity management.
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