The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

Turn the temperature up in the birth room.

Bathe the infant immediately after birth.

Place the infant on the mother's abdomen after birth.

Wrap the infant in a warm, dry blanket.

Answer and Explanation

The Correct Answer is C

Place the infant on the mother's abdomen after birth. This will help the infant maintain an adequate body temperature by providing skin-to-skin contact with the mother, which reduces heat loss and promotes bonding. Skin-to-skin contact also stimulates the baby's natural feeding cues and helps initiate breastfeeding.

Choice A is not correct because turning up the temperature in the birth room may not be enough to prevent heat loss from the infant, especially if they are wet or exposed to cold surfaces. It may also make the mother uncomfortable or dehydrated.

Choice B is not correct because bathing the infant immediately after birth may increase heat loss from evaporation and conduction. It may also interfere with the baby's natural protective coating (vernix) and microbiome. Bathing should be delayed until at least 24 hours after birth.

Choice D is not correct because wrapping the infant in a warm, dry blanket may not provide the same benefits as skin-to-skin contact with the mother. It may also prevent the baby from smelling and seeing the mother's breast, which are important cues for breastfeeding initiation.

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Correct Answer is D

Explanation

Ineffective airway clearance related to mucus and water secretions. This is because newborns who are born via cesarean delivery are at risk for respiratory distress due to the lack of compression of the chest during birth. This can result in retained mucus and fluid in the lungs that can interfere with breathing and oxygenation. The nurse should prioritize clearing the airway and monitoring the respiratory status of the newborn.

Choice A is wrong because ineffective thermoregulation related to heat loss to the environment is not specific to cesarean delivery. All newborns are prone to heat loss due to their large surface area and thin skin. The nurse should maintain a warm and dry environment for the newborn and prevent exposure to cold surfaces.

Choice B is wrong because altered nutrition less than the body requirement related to limited formula intake is not specific to cesarean delivery. All newborns need adequate nutrition to support their growth and development. The nurse should monitor the intake and output of the newborn and assist with feeding as needed.

Choice C is wrong because altered urinary elimination related to post- circumcision status is not specific to cesarean delivery. Circumcision is an elective procedure that may or may not be performed on male newborns. The nurse should provide wound care and pain relief for the circumcised newborn and observe for signs of infection or bleeding.

A. asymmetrical chest movement B. respiratory rate of 50 breaths/minute C. acrocyanosis D. short periods of apnea (less than 15 seconds)

Correct Answer is A

Explanation

Asymmetrical chest movement is a sign of respiratory distress in the newborn, as it indicates unequal lung expansion or airway obstruction. A respiratory rate of 50 breaths/minute (choice B) is normal for a newborn, as is acrocyanosis (choice C), which is a bluish discoloration of the hands and feet due to immature peripheral circulation. Short periods of apnea (less than 15 seconds) (choice D) are also common and benign in newborns unless they are associated with bradycardia or cyanosis.

Choice B is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.

Choice C is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.

Choice D is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.

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The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Correct Answer is D

Explanation

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

Correct Answer is A

Explanation

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A nurse is caring for a postpartum client who saturates a perineal pad in 10 minutes. Which of the following actions should the nurse take first?

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?

Shortly after delivery, a symptom of respiratory distress in the newborn that should be reported is: