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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:
A. "Take a stool softener daily.": Preventing straining during bowel movements is critical after retinal surgery because increased intraocular pressure from straining can disrupt the surgical repair. Stool softeners help maintain soft stools and reduce the risk of increased eye pressure.

B. "You can lift objects that weigh 15 pounds.": Clients should avoid heavy lifting after retinal surgery to prevent increased intraocular pressure. The amount of weight considered safe is minimal, and lifting anything heavier can compromise the surgical site.

C. "Avoid reading for 3 days following surgery.": Light visual activities like reading are usually permitted after surgery, depending on provider instructions. Complete restriction is unnecessary, though clients should avoid activities that increase eye strain or involve prolonged downward gaze.

D. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure, which can compromise the retina. Clients should be instructed to bend at the knees and keep the head upright when picking up objects to protect the surgical repair.

A. "You can obtain a personal response system that will be activated if you fall." B. "You should contact a family member once a week to keep in touch." C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you." D. "You need to move to a skilled nursing facility where they can prevent falls."

Correct Answer is A

Explanation

Rationale:
A. "You can obtain a personal response system that will be activated if you fall.": A personal emergency response system allows the client to summon help immediately after a fall, promoting independence and safety for individuals living alone.

B. "You should contact a family member once a week to keep in touch.": Weekly contact provides emotional support but does not ensure timely assistance in the event of a fall. Regular communication is helpful, yet it does not directly reduce fall risk or guarantee safety if an emergency occurs.

C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Having a UAP visit daily may not be realistic or necessary, especially for independent seniors. This does not provide continuous supervision or an immediate response in case of a fall occurring outside scheduled visits.

D. "You need to move to a skilled nursing facility where they can prevent falls.": Suggesting relocation is premature and disregards the client’s desire for independence. Fall prevention strategies and assistive technology should be explored before recommending institutional care.

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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?

Nursing Test Bank

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