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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The nurse should use the lower ribcage border to measure chest circumference.

Choice A rationale:

The sternal notch is not an appropriate landmark for measuring chest circumference. It is a notch at the top of the sternum and not indicative of chest circumference.

Choice B rationale:

When measuring the chest circumference of a newborn, the correct anatomical landmark to use is the nipple line. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards. It's important to position the measuring tape at the level of the nipples, encircling the chest at its largest point, which typically aligns with the nipple line.

Choice C rationale:

The lower ribcage border is also not suitable as it may vary significantly with respiratory movements and is not a stable landmark for consistent measurements.

Choice D rationale:

The axillae (armpits) are not used as a landmark for measuring chest circumference. It is not a standardized anatomical point for this purpose.

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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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?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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