The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?
Metabolic alkalosis.
Metabolic acidosis.
The infant is hungry.
The infant is overstimulated.
The Correct Answer is B
A. This condition typically results from excessive loss of acid, often due to vomiting or diuretics. It is not the most likely concern in a cold environment with an infant who has been crying and kicking.
B. A cold environment can lead to nonshivering thermogenesis in newborns, where they metabolize brown fat to generate heat. This process can lead to increased lactic acid production, potentially causing metabolic acidosis. The infant's fatigue following crying and kicking may indicate that the body has expended significant energy to stay warm, making metabolic acidosis a priority concern.
C. While hunger could be a reason for crying, it is not the priority concern in this scenario where environmental cold and fatigue are present.
D. Overstimulation might cause crying, but the environmental cold and subsequent risk of metabolic acidosis are more critical concerns in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Iron will facilitate bone growth. This statement is not accurate in the context of feeding a newborn with iron-fortified formula. While iron is essential for overall growth and development, its primary role is not specifically related to bone growth. Instead, it plays a crucial role in the production of hemoglobin, which helps carry oxygen in the blood.
Choice B rationale:
Newborns do not metabolize iron adequately. This statement is the correct choice. Newborns have limited iron stores that are obtained from their mothers during pregnancy. As they grow, their iron requirements increase, but their ability to metabolize iron is not fully developed at
birth. Hence, iron-fortified formula is recommended to provide the necessary iron for the newborn's healthy development.
Choice C rationale:
The newborn's iron source will start to deplete. This statement is not accurate in the context of iron-fortified formula feeding. The newborn's initial iron source is the iron stores passed on by the mother during pregnancy. However, the iron-fortified formula is designed to supplement and fulfill the baby's iron needs, preventing depletion of iron stores.
Choice D rationale:
Iron will facilitate eyesight development. This statement is not entirely accurate. While iron is important for many bodily functions, including eye health, it is not specifically responsible for eyesight development in newborns. Visual development in newborns is influenced by various factors, but iron intake through formula feeding directly impacting eyesight is not a primary concern.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.
Choice B rationale:
The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.
Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.
Choice D rationale:
The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.
Choice C rationale:
Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.
Choice E rationale:
The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.
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