The nurse is caring for a term infant immediately following delivery.Which action should the nurse implement to reduce the risk of cold stress?
Bathe the newborn in warm water and swaddle in 2 blankets.
Place the newborn on the radiant warmer.
Maintain a room temperature above 70° F (21.1° C).
Dry off the newborn and place skin-to-skin.
The Correct Answer is D
Choice A rationale
Bathing the newborn in warm water and swaddling in 2 blankets is not the best immediate action to prevent cold stress. While keeping the newborn warm is crucial, bathing immediately after birth can lead to rapid heat loss, and swaddling alone may not provide sufficient warmth.
Choice B rationale
Placing the newborn on a radiant warmer is an effective method to prevent cold stress, but it is not as beneficial as skin-to-skin contact, which provides both warmth and bonding. Radiant warmers are used primarily in situations where the infant requires stabilization or when skin-to-skin is not feasible.
Choice C rationale
Maintaining a room temperature above 70° F (21.1° C) helps to create a warmer environment, but it does not address the immediate need to prevent heat loss in the newborn. Room temperature alone may not be adequate to prevent cold stress, especially in preterm or low birth weight infants.
Choice D rationale
Drying off the newborn and placing them skin-to-skin with the mother is highly effective in preventing cold stress. This technique promotes thermal regulation through direct skin contact, which transfers body heat from the mother to the infant, stabilizes body temperature, and supports bonding and breastfeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Providing multidisciplinary resources and ongoing support is crucial for newborns exposed to methadone. This approach helps in managing withdrawal symptoms and ensures the child receives comprehensive care.
Choice A rationale
Keeping the newborn in the nursery may be beneficial initially but does not address the long-term needs of the child and the family.
Choice C rationale
Administering methadone to the newborn is not typically done unless specifically indicated by the healthcare provider.
Choice D rationale
Calling social services for foster care placement may be necessary in some cases, but providing support and resources to the mother and child is the primary intervention.
Correct Answer is A
Explanation
Choice A rationale
Assessing the fetal heart rate and client's contraction pattern is the highest priority when a large amount of bright red vaginal bleeding occurs. It is crucial to evaluate fetal well-being and the progression of labor to determine any immediate interventions needed to ensure the safety of both the mother and fetus.
Choice B rationale
Confirming Rh and Coombs status for Rho(D) immunoglobulin administration is important for Rh-negative mothers, but it is not the immediate priority in the presence of significant vaginal bleeding. Ensuring fetal and maternal stability takes precedence over Rh status confirmation.
Choice C rationale
Determining fetal position by performing Leopold maneuvers is not the highest priority when there is significant vaginal bleeding. While fetal position is relevant, immediate assessment of fetal heart rate and maternal contraction pattern is more critical for evaluating the urgency of the situation.
Choice D rationale
Performing a sterile vaginal examination to determine dilation is contraindicated in the presence of vaginal bleeding, as it can exacerbate the situation and lead to further complications. Immediate assessment of fetal well-being and maternal condition is more crucial before considering any internal examination. .
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