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?
Two hours since last eating.
Temperature 36.2°C axillary on radiant warmer.
Drying of the umbilical cord.
Stable temperature for 2 hours.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
15 mL is not the correct choice because it only considers the first two feedings and does not account for the intake during the entire shift.
Choice B rationale:
30 mL is not the correct choice because it only considers the first three feedings and does not account for the intake during the entire shift.
Choice C rationale:
45 mL is not the correct choice because it only considers the first four feedings and does not account for the intake during the entire shift.
Choice D rationale:
The nurse should record 60 mL of formula as the newborn's intake for the shift. To calculate the total intake, you add the amounts from each feeding: 0.5 oz + 1 oz + 0.5 oz + 0.5 oz + 0.5 oz = 60 mL. Remember that 1 fluid ounce (oz) is approximately equal to 30 mL.
Correct Answer is C
Explanation
Choice A rationale:
Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.
Choice B rationale:
Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.
Choice C rationale:
The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.
Choice D rationale:
Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.
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