An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
chart the normal axillary temperature.
recheck the infant's temperature rectally.
place the infant in a radiant warmer.
have the mother breastfeed the infant.
The Correct Answer is C
Choice A reason:
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
Choice B reason:
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
Choice C reason:
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
Choice D reason:
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Lochial color changes from rubra to alba in the early postpartum period is a normal event. Lochia is the vaginal discharge that occurs after childbirth, and it progresses from bright red (rubra) to pink or brownish (serosa) to whitish-yellow (alba) as the days pass.
Choice B reason:
Extreme hunger and thirst in the early postpartum period may indicate abnormal blood sugar levels and can be a sign of gestational diabetes or other metabolic disorders. It requires further evaluation and monitoring by healthcare providers.
Choice C reason:
Diuresis (increased urination) and diaphoresis (increased sweating) are normal events in the early postpartum period. After childbirth, the body eliminates excess fluid that was retained during pregnancy, leading to increased urination and sweating.
Choice D reason:
Flatulence (passing gas) and constipation can be normal events in the early postpartum period due to the body recovering from the effects of labor, changes in diet, and the use of pain medications during childbirth.
Correct Answer is C
Explanation
Choice A reason:
This is incorrect because WIC does not provide immunizations for high-risk infants and children. Immunizations are provided by other health care services, which WIC may refer participants to.
Choice B reason:
This is incorrect because WIC does not screen for infants with developmental disorders. WIC provides nutrition education and referrals to other health and social services but does not diagnose or treat any medical conditions.
Choice C reason:
This is correct because WIC provides supplemental food supplies to low-income pregnant or breastfeeding women, as well as infants and children up to age 5 who are at nutritional risk. The food packages are designed to meet the special nutritional needs of the participants and include items such as fruits, vegetables, milk, cheese, cereal, bread, juice, peanut butter, eggs, and infant formula.
Choice D reason:
This is incorrect because WIC does not provide well-child examinations for infants and children living at the poverty level. WIC may refer participants to other health care services that provide such examinations but do not conduct them themselves.
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