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 A
Explanation
Choice A Reason: Macrosomic fetus is a fetus that weighs more than 4000 grams or 8 pounds 13 ounces at birth. It is not a common complication of teenage pregnancy, but rather of maternal diabetes, obesity, or a history of large babies.
Choice B Reason: Preeclampsia is a condition characterized by high blood pressure and proteinuria in pregnancy. It can cause serious complications for both the mother and the baby, such as seizures, organ damage, growth restriction, and placental abruption. Teenage pregnancy is a risk factor for preeclampsia, especially if the mother is younger than 15 years old.
Choice C Reason: Inadequate nutritional status of mother is a condition where the mother does not consume enough calories, protein, vitamins, minerals, or fluids during pregnancy. It can affect the growth and development of the baby and increase the risk of low birth weight, preterm birth, and birth defects. Teenage pregnancy is a risk factor for inadequate nutritional status of mother, as teenagers may have poor dietary habits, eating disorders, or limited access to food.
Choice D Reason: Cephalopelvic disproportion is a condition where the size or shape of the baby's head or body is too large to fit through the mother's pelvis. It can prevent normal vaginal delivery and require cesarean section. Teenage pregnancy is a risk factor for cephalopelvic disproportion, as teenagers may have smaller or immature pelvises that are not fully developed.
Correct Answer is A
Explanation
Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.
Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic fluid, which can be cleared by suctioning or burping.
Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.
Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not affect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.
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