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 C

Explanation

ask the client to empty her bladder. A full bladder can cause the uterus to be displaced and lead to excessive bleeding. The moderate lochia rubra, normal temperature, soft breasts, firm fundus, slightly deviated to the right, pulse rate of 88/min, and respiratory rate of 18/min are all normal findings.

Choice A is not correct because the client's milk will come in regardless of nursing frequency.

Choice B is not correct because the client's temperature is within normal limits.

Choice D is not correct because there is no indication of an increase in IV fluids.

A. Mucus draining from the nose B. Cyanosis of the hands and feet C. Irregular heart rate D. Sternal or chest retractions

Correct Answer is D

Explanation

Sternal or chest retractions. This is because sternal or chest retractions are a sign of respiratory distress in newborns, which means they are having difficulty breathing. Chest retractions occur when the baby's chest pulls in with each breath, indicating that they are using extra muscles to breathe. This can be caused by various conditions that affect the lungs, such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pneumonia, or congenital heart defects.

Choice A is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.

Mucus drainage does not interfere with breathing unless it is excessive or thick.

Choice B is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported.

Choice C is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs³.

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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

A nurse is collecting data from a client who delivered 2 hours ago. The client has moderate lochia rubra, temperature within normal limits, breasts soft, fundus firm, slightly deviated to the right, pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

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