A newborn is experiencing symptoms of cold stress. Which assessment data by the nurse will require further evaluation for stress protocol? (Select All that Apply.)
Tachycardia
Shivering
Hypoglycemia
Lethargy
Hypertonia
Correct Answer : A,C,D
A. Tachycardia: A compensatory response to cold stress as the infant tries to generate heat.
B. Shivering: Rare in newborns due to immature thermoregulation; not a common finding.
C. Hypoglycemia: Cold stress increases glucose consumption, risking hypoglycemia.
D. Lethargy: A late sign indicating worsening cold stress and potential hypothermia.
E. Hypertonia: Unrelated to cold stress, which more commonly causes hypotonia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Respiratory Status: The newborn is exhibiting signs of respiratory distress, including a respiratory rate of 100/min, grunting, nasal flaring, and substernal retractions. These findings indicate compromised respiratory function, which requires immediate attention to prevent hypoxemia or respiratory failure. The diffuse radiopaque areas on the chest x-ray suggest a condition like transient tachypnea of the newborn (TTN) or respiratory distress syndrome (RDS), common in low-birth-weight infants.
Temperature: After stabilizing the respiratory status, addressing the newborn’s temperature is important. The temperature of 36.3°C (97.3°F) indicates mild hypothermia, which can further compromise respiratory function and glucose metabolism if not corrected. Warming the infant with skin-to-skin contact or using a radiant warmer is necessary to maintain thermoregulation.
Correct Answer is A
Explanation
A. The entry of air into the alveoli, replacing expelled amniotic fluid, is a critical mechanical stimulus that initiates the transition to neonatal breathing.
B. Decreased oxygen levels trigger chemical, not mechanical, stimuli.
C. The diaphragm moves downward during inspiration, not upward.
D. Drying and stimulation help initiate breathing through sensory stimulation, not mechanical.
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