A nurse is caring for a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6" F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?

Dry and stimulate newborn with towel.

Place a hat on the newborn's head.

Maintain the delivery room temperature at 20° C (68° F)

Place a blanket on top of maternal dent and newborn.

Answer and Explanation

The Correct Answer is C

A) Dry and stimulate newborn with towel:
Drying and stimulating the newborn immediately after birth is a standard practice to prevent heat loss and promote early bonding. This action helps to prevent heat loss through evaporation and stimulates the newborn to breathe. It is an appropriate intervention to reduce the risk of hypothermia, not increase it.

B) Place a hat on the newborn's head:
Placing a hat on the newborn’s head is an appropriate and helpful intervention. Since a significant amount of heat is lost through the head, especially in newborns who have a larger surface area relative to their body mass, keeping the head covered with a hat helps to retain warmth and reduce the risk of hypothermia. This would not place the newborn at risk for hypothermia.

C) Maintain the delivery room temperature at 20° C (68° F):
A delivery room temperature of 20° C (68° F) is on the lower end of the recommended range for newborn care. Newborns are particularly susceptible to heat loss due to their high surface area-to-body weight ratio and immature thermoregulation system. A cooler environment like 20°C increases the risk of hypothermia, as the newborn will lose heat more quickly than it can generate on its own.

D) Place a blanket on top of maternal and newborn:
Placing a blanket over the mother and newborn is an appropriate intervention to prevent heat loss. This promotes warmth by reducing heat loss from the newborn's body surface to the cooler environment. This would not place the newborn at risk for hypothermia; instead, it helps to maintain body temperature.

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Correct Answer is C

Explanation

A) Goodell’s sign:
Goodell's sign refers to the softening of the cervix that occurs early in pregnancy, typically around 4–6 weeks. It is a probable sign of pregnancy due to increased vascularity and hormonal changes. However, it does not describe the movement of the fetus or the sensation felt by the provider when pressure is applied to the cervix.

B) Lightening:
Lightening refers to the sensation of the fetus dropping or descending into the pelvic cavity, which typically happens in the later stages of pregnancy (around 36 weeks or later). It is not related to the fetal movement felt by the provider through upward pressure on the cervix, but rather to the physical repositioning of the fetus as it prepares for labor.

C) Ballottement:
Ballottement is the correct term for the movement of the fetus that can be felt by the provider when upward pressure is applied to the cervix. This technique involves a gentle tapping or pushing on the cervix, causing the fetus to rise and then "bounce" back. This is a probable sign of pregnancy, typically noticeable between 16 and 18 weeks gestation.

D) Chadwick's sign:
Chadwick’s sign refers to the bluish discoloration of the cervix, vagina, and vulva due to increased blood flow and is often an early sign of pregnancy. It does not relate to the movement of the fetus felt by the provider, but rather to changes in the color of the genital tissues.

A. Ask the client to empty their bladder B. Perform fundal massage C. Nothing, this is an expected finding D. Ambulate the client in the hallway E. Give pain medications

Correct Answer is ["A","B"]

Explanation

A) Ask the client to empty their bladder:
One of the first actions the nurse should take when the uterus is not firm (often referred to as uterine atony) is to ask the client to empty their bladder. A full bladder can interfere with uterine contraction and cause the uterus to be boggy or soft, which can lead to postpartum hemorrhage. Encouraging the client to void may help the uterus contract more effectively and reduce the risk of complications.

B) Perform fundal massage:
If the uterus is not firm, performing a fundal massage is essential. Fundal massage helps stimulate uterine contractions and helps the uterus contract to its normal size, reducing the risk of bleeding. It is a critical intervention in postpartum care to ensure that the uterus remains firm and does not become atonic, which can cause excessive blood loss.

C) Nothing, this is an expected finding:
A soft uterus (uterine atony) is not an expected finding 4 hours postpartum. A firm uterus is expected at this point to prevent hemorrhage. The nurse should take immediate action to address the issue of uterine atony, as failure to do so can lead to significant postpartum hemorrhage, a life-threatening complication.

D) Ambulate the client in the hallway:
Ambulation may be helpful later in the postpartum period to encourage circulation and prevent thromboembolism, but it is not a priority when the uterus is not firm. The first priority is to address uterine atony, and actions like emptying the bladder and massaging the fundus should be performed before ambulating the client.

E) Give pain medications:
While pain management is important, it is not the priority intervention when the uterus is not firm. The nurse must first address the cause of uterine atony (such as bladder distention) and stimulate uterine contractions via fundal massage to ensure that the uterus is firm and the client is not at risk for excessive bleeding. Pain medications can be given once the immediate uterine concerns have been addressed.

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A nurse is caring for a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6" F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing probable signs of pregnancy with a newly licensed nurse. Which of the following terms should the nurse use to describe the movement of the fetus felt by the provider after placing upward pressure on the cervix?

Correct Answer is C

Explanation

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Correct Answer is ["A","B"]

Explanation

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A nurse is caring for a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6" F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?

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