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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Decrease the client's IV fluids:
Sinusoidal fetal heart rate patterns are concerning and typically indicate severe fetal distress, which is often associated with conditions such as fetal anemia, hypoxia, or central nervous system (CNS) damage. Decreasing IV fluids is not an appropriate response to a sinusoidal pattern. The primary focus should be on fetal well-being, not fluid management, in this situation.

B) Prepare the client for an emergent birth:
This pattern is typically associated with severe fetal compromise and is an ominous sign. Immediate intervention is required, and emergent delivery may be necessary to prevent further fetal distress and potential harm. The nurse should promptly notify the healthcare provider and prepare the client for an emergency cesarean delivery or other urgent interventions.

C) Turn the client to a supine position:
The supine position is not recommended for managing fetal distress, as it may decrease uterine blood flow and worsen the situation, especially if the fetus is experiencing hypoxia. The appropriate intervention for addressing a sinusoidal heart rate pattern is not repositioning the client in a supine position, but rather preparing for emergency delivery and providing immediate support to stabilize both mother and fetus.

D) Document the findings:
While it is important to document any fetal heart rate pattern, sinusoidal patterns require immediate action. Documentation alone is not sufficient in this case, as it does not address the potential life-threatening situation for the fetus. The nurse should not delay action, and the focus should be on preparing for emergency birth and notifying the healthcare provider immediately.

Correct Answer is ["2"]

Explanation

Given:

Desired dose: Ampicillin 0.5 g PO

Available concentration: Ampicillin capsules 250 mg each

To find:

Number of capsules to administer for a single dose

Step 1: Convert desired dose to milligrams

We know that 1 gram (g) is equal to 1000 milligrams (mg). Therefore, to convert the desired dose from grams to milligrams, we multiply by 1000:

Desired dose (mg) = Desired dose (g) x 1000

Desired dose (mg) = 0.5 g x 1000 = 500 mg

Step 2: Calculate the number of capsules

To find the number of capsules, we divide the desired dose by the strength of each capsule:

Number of capsules = Desired dose / Capsule strength

Number of capsules = 500 mg / 250 mg/capsule = 2 capsules

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 analyzing a fetal heart monitor strip and identifies a sinusoidal fetal heart rate pattern, which has been occurring for 30 min. Which of the following actions should the nurse take at this time?

Correct Answer is B

Explanation

A client is ordered ampicillin 0.5 g po every 6 hours. On hand are ampicillin capsules labeled 250mg. How many capsules will the nurse administer for single dose?

Correct Answer is ["2"]

Explanation

Which of the following is an example of a primitive reflex that is present in newborns and typically disappears by 3-4 months of age?

A nurse on a postpartum caring for a client. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

A nurse is teaching a student nurse about the anticipated care of a maternal client with ruptured membranes during the second stage of labor. Which of the following statements by the student indicates an understanding of the teaching?

A nurse is assessing a client who is 8 hour postpartum. Where should the nurse expect to find the fundus?

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

A nurse is planning care for a client in labor and delivery. Which of the following activities should the nurse plan to demonstrate working at the highest level of their license?

A nurse is working with a client who is 6 hour postpartum following a vaginal birth with first -degree laceration. Which of the following, actions is an example of the nurse providing a stepwise approach to manage the client's pain?

The nurse is aware that fibrinogen levels are increased in pregnancy. Which measure can be taken to prevent postpartum complications that result because of this increase? Have the client: