A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour.
Maintaining the newborn's body temperature is important for preventing:
Respiratory depression.
Tachycardia.
Cold stress.
Vasoconstriction.
The Correct Answer is C
Choice A rationale
Maintaining the newborn's temperature is critical to prevent cold stress, which can lead to metabolic acidosis. Cold stress can increase oxygen consumption, leading to respiratory distress (tachypnea, grunting, nasal flaring), but it does not directly cause primary respiratory depression (decreased rate and depth), which is more commonly associated with maternal medications or central nervous system issues.
Choice B rationale
Cold stress initiates a cascade of events to generate heat (non-shivering thermogenesis), primarily through the metabolism of brown fat. This increased metabolic rate, coupled with increased oxygen consumption, typically results in tachycardia (increased heart rate, normal range 110-160 beats/min) as the heart attempts to circulate oxygen more rapidly, rather than preventing it; therefore, preventing tachycardia is not the primary goal.
Choice C rationale
Maintaining a neutral thermal environment (NTE) using a radiant warmer is essential for preventing cold stress, which occurs when the newborn must increase metabolic heat production to maintain a normal body temperature (36.5° C to 37.5° C). This stress rapidly depletes glucose and oxygen stores, potentially leading to metabolic acidosis, hypoglycemia, and respiratory distress.
Choice D rationale
In an effort to conserve core heat during cold stress, the newborn's peripheral blood vessels undergo vasoconstriction, leading to acrocyanosis. This physiological response is part of the cold stress mechanism. Preventing cold stress is the goal, which in turn prevents the need for vasoconstriction and the resulting metabolic demands.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Terbutaline is a β_2-adrenergic agonist, which primarily relaxes the smooth muscle of the uterus to suppress preterm labor. A common side effect is maternal hypotension due to vasodilation, rather than hypertension, as the drug stimulates β_2 receptors in the vascular smooth muscle, decreasing peripheral vascular resistance. The nurse should, therefore, monitor for a decrease in blood pressure, not an increase.
Choice B rationale
Terbutaline is a non-selective β-agonist, stimulating β_1 receptors in the heart in addition to the uterine β_2 receptors. Stimulation of β_1 receptors increases the heart rate and contractility, leading to maternal tachycardia (heart rate typically ≥ 120 beats/min is considered a serious adverse effect). This cardiovascular effect is a significant concern that the nurse must monitor closely for and report.
Choice C rationale
The β-agonist effect of terbutaline also crosses the placenta, potentially causing fetal tachycardia, not bradycardia, due to β_1 stimulation of the fetal heart. The drug's primary action on the uterus is relaxation, which improves uteroplacental perfusion, but the cardiac side effect is the concern, requiring fetal heart rate monitoring for signs of distress.
Choice D rationale
Terbutaline has numerous known adverse effects due to its β-adrenergic agonist properties. Common side effects include maternal and fetal tachycardia, palpitations, chest pain, tremors, headache, and potential hyperglycemia or hypokalemia. Stating there are no known adverse effects is scientifically incorrect, as pharmacologic agents inherently carry potential risks.
Correct Answer is B
Explanation
Choice A rationale
Adjusting the Pavlik harness straps is contraindicated, as the healthcare provider specifically set them to maintain the infant's hips in the optimal position of flexion and abduction, necessary for proper acetabular development. Frequent adjustment risks altering the prescribed angle, which could compromise treatment efficacy by allowing hip adduction or extension. Straps should only be adjusted by the provider during scheduled appointments to ensure optimal orthopaedic correction and joint congruence.
Choice B rationale
The Pavlik harness is designed to hold the femoral head within the acetabulum, promoting proper development but creating localized pressure points. Regular skin checks (e.g., three times daily or with diaper changes) are vital to detect signs of skin breakdown, redness, or irritation, especially under the straps and at pressure areas like the popliteal folds, which could lead to pressure ulcers or dermatitis if not addressed promptly by adjusting the padding or seeking provider consultation.
Choice C rationale
The diaper must be placed under the harness straps to prevent fecal or urinary soiling of the harness material, maintaining hygiene and preventing skin irritation from moisture trapped by the harness. Placing the diaper over the harness would necessitate unbuckling the leg straps for each change, which could disrupt the precisely set hip position required for therapeutic hip abduction and flexion.
Choice D rationale
Lotions and powders should be avoided under the harness or on skin areas in contact with the straps. These products can clump or retain moisture, leading to maceration and increased friction, which predisposes the skin to breakdown, dermatitis, and potential infection. Skin in contact with the harness should be kept clean and dry, allowing aeration to maintain skin integrity.
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