The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to:
Select one:
Place the infant skin to skin with the mother and re-check temperature in 30 minutes.
Check the infant's CBC and blood cultures, as this is a sign of probable sepsis.
Return the infant to the nursery for close observation under warming lights.
Notify the physician immediately and suggest orders for placement in an incubator.
The Correct Answer is A
Choice A Reason: Place the infant skin to skin with the mother and re-check temperature in 30 minutes. This is because skin-to-skin contact is an effective and safe method of increasing the infant's temperature and promoting thermoregulation. Skin-to-skin contact also has other benefits such as enhancing bonding, breastfeeding, and maternal-infant attachment.
Choice B Reason: Check the infant's CBC and blood cultures, as this is a sign of probable sepsis. This is an unnecessary action that may cause undue stress and discomfort to the infant and the mother. A slightly decreased temperature in a full-term infant is not a sign of probable sepsis, but rather a common finding that may be due to environmental factors, such as exposure to cold air or wet linens.
Choice C Reason: Return the infant to the nursery for close observation under warming lights. This is an undesirable action that may interfere with the early initiation of breastfeeding and bonding between the mother and the infant. Warming lights are not recommended for routine use in healthy newborns, as they may cause dehydration, hyperthermia, or eye damage.
Choice D Reason: Notify the physician immediately and suggest orders for placement in an incubator. This is an excessive action that may indicate a lack of knowledge or confidence on the part of the nurse. An incubator is not indicated for a stable, full term infant with a slightly decreased temperature, as it may expose the infant to unnecessary interventions, infections, or separation from the mother.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: Macrosomic newborn. This is a correct answer that describes a possible complication of post-term pregnancy. A macrosomic newborn is a newborn that weighs more than 4000 grams or 8 pounds 13 ounces at birth. It can occur in post-term pregnancies due to prolonged exposure to maternal glucose and insulin. It can increase the risk of birth injuries, shoulder dystocia, cesarean delivery, and hypoglycemia.
Choice B Reason: Intrauterine growth restriction (IUGR). This is a correct answer that indicates a potential problem of post-term pregnancy. IUGR is a condition where the fetal growth is slower than expected for gestational age. It can occur in post-term pregnancies due to placental insufficiency, aging, or calcification, which can impair nutrient and oxygen delivery to the fetus. It can increase the risk of fetal distress, hypoxia, acidosis, and stillbirth.
Choice C Reason: Umbilical cord prolapse. This is an incorrect answer that does not reflect a risk of post-term pregnancy, but rather a risk of other factors such as prematurity, low birth weight, breech presentation, multiple gestation, polyhydramnios, or artificial rupture of membranes.
Choice D Reason: Meconium Aspiration Syndrome (MAS). This is a correct answer that denotes a possible complication of post-term pregnancy. MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inflammation, and infection. MAS usually affects term or post-term infants who experience fetal distress or hypoxia in utero. It can cause respiratory distress syndrome (RDS), persistent pulmonary hypertension (PPHN), or chronic lung disease (CLD).
Correct Answer is D
Explanation
Choice A Reason: "Your body is responding to the events of labor, just like after a tough workout." This is an inaccurate statement that does not explain the cause of the contractions or reassure the client.
Choice B Reason: "This could be a sign that your body is trying to get rid of retained placental fragments." This is an alarming statement that may scare the client and imply that something is wrong. Retained placental fragments are rare and usually cause heavy bleeding, fever, and infection.
Choice C Reason: "Let me check your vaginal discharge just to make sure everything is fine." This is an unnecessary statement that does not answer the client's question or provide any information.
Choice D Reason:"The baby's sucking releases oxytocin which causes your uterus to contract." This is a correct statement that explains the physiological mechanism of the contractions and reassures the client that they are normal and beneficial.
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