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.

Answer and Explanation

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.

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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.

A. Increased intracranial pressure. B. Vernix caseosa. C. Dehydration. D. Cyanosis.

Correct Answer is C

Explanation

The correct answer is c. Dehydration. A significantly indented anterior fontanelle in a newborn is most commonly a sign of dehydration.

Choice A reason:

Increased intracranial pressure: This statement is incorrect because increased intracranial pressure typically causes a bulging, not indented, fontanelle. Symptoms include irritability, vomiting, and a high-pitched cry.

Choice B reason:

Vernix caseosa: This statement is incorrect because vernix caseosa is a white, cheesy substance covering the skin of newborns, unrelated to fontanelle indentation. It serves as a protective layer for the baby’s skin.

Choice C reason:

Dehydration: This statement is correct. Dehydration in newborns can cause a sunken fontanelle due to the loss of fluid. Other signs include dry mouth, sunken eyes, and fewer wet diapers.

Choice D reason:

Cyanosis: This statement is incorrect because cyanosis refers to a bluish discoloration of the skin due to lack of oxygen, not related to fontanelle shape. It indicates issues with oxygenation or circulation.

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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?

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Correct Answer is D

Explanation

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Correct Answer is C

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