A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Drying the newborn's skin thoroughly

Preventing air drafts

Placing the newborn on a warm surface

Maintaining ambient room temperature at 24° C (75" F)

Answer and Explanation

The Correct Answer is A

A.   Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B.   Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface helps prevent conductive heat loss.
D.   Maintaining ambient room temperature is important but does not directly address evaporative heat loss.

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Correct Answer is A

Explanation

A. This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B. A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D. While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.

A. Document the findings and continue to monitor the client. B. Encourage the client to empty her bladder. C. Increase the frequency of fundal massage. D. Notify the client’s provider.

Correct Answer is A

Explanation

A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.

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A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant who is small for her gestational age (SGA). Which intervention is of highest priority for this infant who is at risk for hypoglycemia?

Correct Answer is A

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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