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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. This is not a primary consideration before bathing a newborn. The timing of the last feeding is more relevant to assessing the risk of hypoglycemia rather than determining readiness for a bath.

B. This temperature is slightly below the recommended range for newborns (36.5°C to 37.5°C). Bathing should be delayed until the newborn's temperature is stable.

C. While care of the umbilical cord is important, it does not determine the timing of the first bath. The cord can be kept dry even if the baby is bathed.

D. Ensuring that the newborn has maintained a stable body temperature for at least 2 hours is crucial before giving the first bath. Bathing can cause a drop in body temperature, so it's essential that the newborn's thermoregulation is stable to avoid hypothermia.

A. The nurse should first report the client's laboratory results to the primary health care. B. The nurse should first report the client's respiratory status to the primary health care. C. The nurse should first report the client's brachial pulses to the primary health care.

Correct Answer is B

Explanation

The nurse should first report the client's respiratory status to the primary health care.

Choice A rationale:

Reporting the client's laboratory results to the primary health care is important, but in a newborn with respiratory distress and acidosis, addressing the respiratory status takes precedence. The priority is to ensure the newborn's respiratory stability and adequate oxygenation.

Choice B rationale:

Reporting the client's respiratory status to the primary health care is the correct action. A newborn with respiratory distress syndrome and respiratory acidosis requires immediate attention. The primary health care provider needs to be informed promptly to make decisions about further interventions and management.

Choice C rationale:

Reporting the client's brachial pulses to the primary health care is essential, but it is not the priority in this situation. The primary concern is the newborn's respiratory distress and acidosis, which needs to be addressed first.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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