Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
Cold stress.
Respiratory depression.
Thermogenesis.
Tachycardia.
The Correct Answer is A
Choice A rationale:
Placing the newborn under a radiant heat warmer is used to prevent cold stress. Newborns are at risk of losing body heat rapidly, and cold stress can lead to various complications, including respiratory distress, hypoglycemia, and metabolic acidosis. The radiant heat warmer helps maintain the baby's body temperature within the normal range, promoting overall stability and reducing the risk of cold-related issues.
Choice B rationale:
The nurse should not choose choice B, "Respiratory depression,” as the action used to prevent. Placing the newborn under a radiant heat warmer does not specifically target respiratory depression. Respiratory depression in newborns may be related to various factors, such as anesthesia exposure during delivery or certain medications, and it requires appropriate monitoring and management rather than just heat regulation.
Choice C rationale:
The nurse should not choose choice C, "Thermogenesis,” as the action used to prevent. Thermogenesis refers to the generation of heat in the body, which is essential for maintaining body temperature. While the radiant heat warmer indirectly supports thermogenesis by preventing heat loss, the main purpose of using the warmer is to prevent cold stress, as stated in choice A.
Choice D rationale:
The nurse should not choose choice D, "Tachycardia,” as the action used to prevent. Tachycardia refers to an abnormally fast heart rate, and the use of a radiant heat warmer does not specifically target this condition. The purpose of the warmer, as explained earlier, is to maintain the baby's body temperature and prevent cold stress, not to address tachycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
During the transition phase of labor, the nurse should encourage the client to use a pant- blow breathing pattern. The transition phase is intense, and pant-blow breathing (a form of controlled breathing) can help the client manage the pain and reduce anxiety. Panting during contractions allows the client to focus on short, shallow breaths, which can be more effective than deep breathing during this stage.
Choice A rationale:
Assisting the client to void every 3 hours is important during labor, but it is not specific to the transition phase. The nurse should encourage the client to void regularly during the entire labor process to prevent bladder distension and facilitate the descent of the baby. However, during the transition phase, the client may be more focused on contractions and may not need reminders to void every 3 hours.
Choice B rationale:
Monitoring contractions every 30 minutes is not appropriate during the transition phase of labor. The transition phase is characterized by frequent and strong contractions, and continuous monitoring of contractions is usually required during this phase to ensure fetal well-being and progress in labor.
Choice C rationale:
Placing the client into a lithotomy position is not appropriate during the transition phase of labor. The lithotomy position, where the client lies on their back with legs raised and supported in stirrups, is often used during the pushing phase. During the transition phase, it is more common for the client to be in an upright or semi-reclining position to facilitate the descent of the baby through the birth canal.
Correct Answer is C
Explanation
Choice A rationale:
While there is a risk of infection with any internal examination, it is not the primary reason for avoiding internal examinations in a client with placenta previa. The main concern is avoiding trauma to the placenta, which could result in significant bleeding.
Choice B rationale:
Although internal examinations may potentially stimulate uterine contractions, leading to preterm labor in some cases, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
Choice C rationale:
The correct explanation for the nurse to provide is that an internal examination could result in profound bleeding. Placenta previa occurs when the placenta partially or completely covers the cervix, and any manipulation of the cervix or uterus through an internal examination could disrupt the placenta and cause severe bleeding, endangering both the mother and the baby.
Choice D rationale:
While there is a risk of rupturing the membranes during an internal examination, this is not the primary reason for avoiding such examinations in clients with placenta previa. The primary concern remains the risk of bleeding due to placental disruption.
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