The correct answer is choice A, which is to ensure that conductive heat loss from the infant is minimal
ensure that conductive heat loss from the infant is minimal
compensate for the negative weight balance to ensure the correct weight
avoid causing multiple startle (Moro) reflexes when weighing
avoid contaminating the nurse's hands with blood or other body substances
The Correct Answer is A
Choice A reason:
Placing a covering on the scale tray when weighing an infant helps to ensure that conductive heat loss from the infant is minimal. Newborns and infants are especially vulnerable to temperature changes, and maintaining their body temperature is crucial for their well-being. By placing a covering, such as a soft cloth or blanket, on the scale tray, the nurse creates a barrier between the infant's skin and the cold surface of the scale. This reduces the risk of heat loss from direct contact with the scale, helping to keep the baby comfortable and preventing any potential adverse effects from exposure to low temperatures during the weighing process.
Choice B reason:
Choice B, compensating for the negative weight balance to ensure the correct weight, is not the primary reason for using a covering on the scale tray. The negative weight balance, if any, would be minimal and not significant enough to affect the accuracy of the infant's weight measurement. The main concern when using a scale for weighing infants is to ensure their comfort and safety during the process.
Choice C reason:
Choice C, avoiding causing multiple startle (Moro) reflexes when weighing, is not the main reason for using a covering on the scale tray. The Moro reflex is a normal startle response in infants and is not typically affected by whether or not a covering is placed on the scale tray.
The nurse can support the infant appropriately during weighing to minimize any startle reflexes, regardless of whether a covering is used.
Choice D reason:
Choice D, avoiding contaminating the nurse's hands with blood or other body substances, is not directly related to using a covering on the scale tray. The primary purpose of using a covering is to minimize heat loss, as explained in Choice A. However, it is standard practice for healthcare professionals to wear gloves when handling blood or body substances to prevent any potential transmission of infections, ensuring both the nurse's and the infant's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Babinski's Reflex is the normal response in infants when the sole of the foot is stroked from the heel to the ball of the foot. The big toe moves upward or toward the top surface of the foot, and the other toes fan out. This reflex is normal in children up to 2 years old, and it disappears as the nervous system matures. It may indicate damage to the central nervous system in older children and adults.
Choice B reason:
Stepping Reflex is the normal response in infants when they are held upright with their feet touching a flat surface. They will lift one foot and then the other, as if they are walking. This reflex is present at birth and lasts for about 2 months. It helps prepare the infant for voluntary walking.
Choice C reason:
Moro Reflex is the normal response in infants when they are startled by a loud noise or a sudden movement. They will extend their arms and legs, open their hands, and then curl up and bring their arms together as if they are hugging themselves. This reflex is present at birth and lasts for about 4 to 6 months. It is thought to be a protective response that helps the infant cling to their caregiver.
Choice D reason:
Plantar Grasp Reflex is the normal response in infants when pressure is applied to the sole of the foot near the toes. The toes will curl down and grasp the stimulus. This reflex is present at birth and lasts for about 9 to 12 months. It is similar to the palmar grasp reflex in the hands, and it helps develop the muscles and nerves in the feet. Some additional sentences are:. If you are interested in learning more about infant development, you can check out some of these links:. • [A guide to newborn reflexes]. • [A video demonstration of newborn reflexes].
Correct Answer is D
Explanation
Choice A reason:
Measuring urinary output. This is not the priority nursing care associated with an oxytocin infusion, because urinary output is not directly affected by oxytocin. Urinary output may be affected by other factors, such as fluid intake, dehydration, or kidney function, but these are not related to oxytocin administration. • Choice B reason:
Evaluating cervical dilation. This is also not the priority nursing care associated with an oxytocin infusion, because cervical dilation is a result of uterine contractions, not oxytocin itself. Oxytocin is used to stimulate or augment uterine contractions, but it does not cause cervical dilation directly. Cervical dilation is important to monitor during labor, but it is not the main focus of oxytocin infusion. • Choice C reason:
Increasing infusion rate every 30 minutes. This is not the priority nursing care associated with an oxytocin infusion, because increasing the infusion rate every 30 minutes is not a standard protocol for oxytocin administration. The infusion rate should be adjusted according to the patient's response and the provider's orders, but not arbitrarily or routinely. Increasing the infusion rate too quickly or too often can cause hyperstimulation of the uterus, which can be dangerous for both the mother and the fetus.
• Choice D reason:
Monitoring uterine response. This is the correct answer and the priority nursing care associated with an oxytocin infusion, because oxytocin can cause excessive or prolonged uterine contractions, which can lead to fetal distress, uterine rupture, or placental abruption. Therefore, the nurse must monitor the frequency, duration, and intensity of uterine contractions, as well as the fetal heart rate and blood pressure, to ensure that oxytocin is having the desired effect and not causing any adverse outcomes.
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