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 D
Explanation
Choice A Reason: Maintain the client on strict bedrest. This is an inappropriate action that may worsen the client's condition and increase her isolation and depression. Postpartum psychosis requires prompt psychiatric treatment with medication and psychotherapy, not bedrest.
Choice B Reason: Carefully monitor intake and output. This is an irrelevant action that has no direct relation to postpartum psychosis or its management. Monitoring intake and output may be indicated for other postpartum complications such as hemorrhage, infection, or preeclampsia.
Choice C Reason: Restrict visitation of the client's partner. This is an unnecessary action that may deprive the client of social support and emotional comfort. The partner may be an important source of help and information for the client and the health care team. The partner should be involved in the client's care and education, unless there are signs of abuse or violence.
Choice D Reason: Closely supervise all infant care and interaction. This is because postpartum psychosis is a severe mental disorder that occurs in some women after childbirth, which can cause delusions, hallucinations, paranoia, mood swings, confusion, and suicidal or homicidal thoughts. Postpartum psychosis can pose a danger to both the mother and the infant, as the mother may harm herself or the infant due to distorted perceptions or impulses. The nurse should closely supervise all infant care and interaction to ensure safety and prevent injury.
Correct Answer is D
Explanation
Choice A Reason: Possible Meconium Aspiration Syndrome (MAS). This is an unlikely condition for this newborn, as 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.
Choice B Reason: Possible polycythemia. This is an unrelated condition for this newborn, as polycythemia refers to an abnormally high number of red blood cells in the blood, which can increase blood viscosity and impair circulation.
Polycythemia may occur in infants who have delayed cord clamping, intrauterine growth restriction, maternal diabetes, or high altitude exposure.
Choice C Reason: Possible Transient Tachypnea of the Newborn (TTN). This is a less serious condition than RDS, as TTN is a mild respiratory problem that results from delayed clearance of fetal lung fluid after birth. TTN causes rapid breathing, nasal flaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth.
Choice D Reason: Possible Respiratory Distress Syndrome (RDS). This is a serious condition that requires immediate intervention and treatment, as RDS can lead to life-threatening complications such as pulmonary hemorrhage, pneumothorax, or bronchopulmonary dysplasia. RDS causes respiratory distress, nasal flaring, retractions, grunting, and central cyanosis. It usually occurs within minutes to hours after birth.
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