When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
Hypothermia.
Deficient fluid volume.
Impaired gas exchange.
Risk for infection.
The Correct Answer is A
Choice A reason:
Hypothermia is the priority area for this newborn because the axillary temperature of 95.8° F (35.4° C) is below the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C) for newborns1. Hypothermia can lead to complications such as hypoglycemia, metabolic acidosis, and impaired oxygen delivery2. The nurse should initiate interventions to warm the newborn, such as skin-to-skin contact, radiant warmer, or swaddling2.
Choice B reason:
Deficient fluid volume is not the priority area for this newborn because the apical pulse of 114 beats per minute is within the normal range of 100 to 160 beats per minute for newborns345. A low pulse rate can indicate dehydration or shock in newborns2. The nurse should monitor the newborn's fluid intake and output, weight, and signs of dehydration, such as dry mucous membranes, sunken fontanels, and poor skin turgor2.
Choice C reason:
Impaired gas exchange is not the priority area for this newborn because the respiratory rate of 60 breaths per minute is within the normal range of 30 to 60 breaths per minute for newborns345. A high or low respiratory rate can indicate respiratory distress or failure in newborns2. The nurse should assess the newborn's breath sounds, chest movements, oxygen saturation, and signs of respiratory distress, such as nasal flaring, grunting, retractions, and cyanosis2.
Choice D reason:
Risk for infection is not the priority area for this newborn because there is no evidence of infection in the vital signs or the question stem. However, newborns are vulnerable to infection due to their immature immune systems and exposure to pathogens during birth and aftercare2. The nurse should follow infection control measures, such as hand hygiene, aseptic technique, and cord care, and educate the parents on how to prevent infection at home2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: the interval between contractions
Encouraging a laboring woman to push during the interval between contractions is not appropriate. During this time, the uterus is not contracting, and pushing would be ineffective and exhausting for the woman. The intervals are meant for rest and recovery to prepare for the next contraction.
Choice B: whenever she feels the need
While it is important to listen to the laboring woman’s instincts, pushing should be coordinated with contractions for maximum effectiveness. Pushing whenever she feels the need might not align with the contractions, leading to ineffective efforts and increased fatigue.
Choice C: second-stage of labor
The second stage of labor is the most appropriate time for the nurse to encourage a laboring woman to push. This stage begins when the cervix is fully dilated to 10 centimeters and ends with the birth of the baby. During this stage, contractions are strong and frequent, providing the necessary force to help push the baby through the birth canal.
Choice D: first-stage of labor
The first stage of labor involves the dilation and effacement of the cervix and is not the appropriate time for pushing. Pushing during this stage can cause unnecessary strain and may lead to complications. The focus during the first stage should be on managing contractions and conserving energy for the second stage.
Correct Answer is D
Explanation
The correct answer is: d. Move infant away from blowing fan.
Choice A: Dry the baby after a bath
Drying the baby after a bath is essential to prevent heat loss through evaporation. When a newborn is wet, the water on their skin can evaporate, taking heat away from their body. While this is an important step in maintaining the baby’s temperature, it does not specifically address heat loss through convection.
Choice B: Wrap the baby in warmed blankets
Wrapping the baby in warmed blankets helps prevent heat loss through conduction and radiation. Conduction occurs when the baby comes into contact with a cooler surface, and radiation occurs when the baby loses heat to the surrounding environment. Although this action is beneficial, it does not directly address heat loss through convection.
Choice C: Place the baby in a warmer
Placing the baby in a warmer is an effective way to maintain the baby’s overall body temperature by providing a controlled, warm environment. This action helps prevent heat loss through conduction, radiation, and evaporation. However, it is not the most direct method to prevent heat loss through convection.
Choice D: Move infant away from blowing fan
Moving the infant away from a blowing fan directly addresses and prevents heat loss due to air movement, which is a key factor in convection. Convection occurs when air currents carry heat away from the baby’s body. By moving the baby away from the fan, the nurse can effectively reduce heat loss through this mechanism.
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