Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).
Respiratory distress.
Hyperglycemia.
Metabolic alkalosis.
Hypoglycemia.
Correct Answer : A,D
Choice A rationale:
Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.
Choice B rationale:
Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.
Choice C rationale:
Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.
Choice D rationale:
Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.
Choice E rationale:
Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Washing the penis with warm water and mild soap each day is not an appropriate statement regarding circumcision care with a Plastibell device. Keeping the area clean is essential, but soap may irritate the wound, and frequent washing can disrupt the healing process.
Choice B rationale:
Ensuring a loose diaper in the front is not directly related to circumcision care with a Plastibell device. It may be relevant for comfort, but it does not address specific care for the circumcision site.
Choice C rationale:
This is a correct statement indicating understanding of circumcision care with the Plastibell device. The plastic ring is expected to fall off on its own within a week, and this is a normal part of the healing process.
Choice D rationale:
Applying petroleum jelly to the penis during diaper changes is not recommended for circumcision care with a Plastibell device. The petroleum jelly can interfere with wound healing and should be avoided.
Choice E rationale:
This is also a correct statement indicating understanding of circumcision care. If bleeding occurs after the Plastibell has fallen off, it could be a sign of a complication, and the doctor should be notified promptly.
Correct Answer is B
Explanation
A. Maintaining ambient room temperature at 24° C (75° F) can help prevent heat loss by keeping the environment warm, but it does not specifically address evaporative heat loss. Evaporative heat loss occurs when moisture on the skin evaporates, which is not directly controlled by ambient temperature.
B. Drying the newborn's skin thoroughly reduces evaporative heat loss by removing moisture that can evaporate and cool the skin. This action is critical immediately after birth when the newborn is wet with amniotic fluid.
C. Preventing air drafts helps reduce convective heat loss, not evaporative heat loss. Convective heat loss occurs when air moves across the skin and carries heat away.
D. Placing the newborn on a warm surface helps reduce conductive heat loss by preventing heat transfer from the baby to a cooler surface. However, this does not address evaporative heat loss, which is specifically related to moisture evaporation from the skin.
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