A nurse is caring for a neonate born vaginally at 0130, at 39 weeks gestation, in the newborn nursery.
The Correct Answer is []
Rationale for correct condition Neonatal temperature of 95.7°F (35.4°C) is below the normal range of 97.7–99.5°F (36.5–37.5°C). Peripheral cyanosis, cool extremities, and absence of feeding suggest inadequate thermal support. Newborns have immature hypothalamic thermoregulatory centers and limited subcutaneous fat. They lose heat via convection, conduction, radiation, and evaporation. The neonate is at risk for cold stress, which increases oxygen consumption and metabolic demands.
Rationale for correct actions Wrapping in a warm blanket reduces heat loss by insulating the neonate and preventing further evaporative and convective heat dissipation. It also stabilizes skin temperature gradients. A radiant warmer provides consistent external heat, preventing hypothermia without compression or discomfort. It maintains neutral thermal environment, critical for term infants adapting to extrauterine life.
Rationale for correct parameters Monitoring temperature is essential to evaluate warming efficacy and detect cold stress early. Rectal temperatures below 36.5°C indicate hypothermia needing intervention. Respiratory rate reflects compensatory effort; cold stress increases oxygen demands leading to tachypnea. Normal neonatal respiratory rate is 30–60 breaths/min; continued elevation may suggest persistent thermal imbalance.
Rationale for incorrect conditions Hypoglycemia may coexist but is not confirmed without glucose level; primary symptoms are jitteriness and poor feeding. Hyperbilirubinemia shows jaundice, not cyanosis. Altered respiratory function includes grunting or nasal flaring, absent in this neonate.
Rationale for incorrect actions Removing wet clothing is helpful only when moisture is present; no wet items noted. Manual breaths are unnecessary as spontaneous respirations are intact. Dextrose treats hypoglycemia, not hypothermia.
Rationale for incorrect parameters Blood glucose levels are relevant only if hypoglycemia suspected. Stool output is unrelated to thermal regulation. Urine output doesn’t reflect temperature stability.
Take-home points • Neonates rapidly lose heat post-delivery due to immature thermoregulation. • Hypothermia increases metabolic demand and respiratory rate. • Radiant warmers and insulated wrapping are primary interventions. • Differentiation from hypoglycemia or respiratory issues ensures proper care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While a high-protein diet is generally healthy, it is not an effective intervention to rapidly correct the anemia associated with preeclampsia. Anemia in preeclampsia is often related to hemolysis, a component of HELLP syndrome, where red blood cells are destroyed. Increasing dietary protein will not reverse this pathophysiological process or correct the underlying cause of the anemia. The normal hemoglobin range is 12.0-15.5 g/dL for women.
Choice B rationale
A hemoglobin level of 9.8 g/dL is considered mild anemia and does not typically warrant a blood transfusion. Transfusions are reserved for severe anemia or acute blood loss. The client's condition is likely related to hemolysis, and transfusion may not address the underlying issue. Transfusion therapy carries risks and is not indicated for this degree of anemia.
Choice C rationale
Seizure precautions are indicated for preeclampsia, but they are not specifically a direct consequence of a low platelet count. A low platelet count, or thrombocytopenia, increases the risk of bleeding. Seizures in preeclampsia are related to cerebral vasospasm and endothelial dysfunction. Implementing seizure precautions is a part of general preeclampsia care, but not directly linked to the platelet count of 120,000/mm³. The normal platelet count is 150,000-450,000/mm³.
Choice D rationale
A platelet count of 120,000/mm³ is below the normal range, indicating thrombocytopenia. This condition impairs the blood's ability to clot, increasing the client's risk for hemorrhage and bruising. Monitoring for signs of bleeding, such as petechiae, purpura, or bleeding from injection sites, is a critical nursing intervention to detect and manage potential bleeding complications promptly.
Correct Answer is D
Explanation
Choice A rationale
The direction and volume of blood flow through a VSD depend on the size of the defect and the pressure difference between the ventricles. A small VSD typically has a left-to-right shunt due to higher systemic pressure. This flow pattern does not typically cause valvular dysfunction, but rather increases pulmonary blood flow.
Choice B rationale
Small VSDs often do not require surgical intervention because they are hemodynamically insignificant and may close on their own. Surgical repair is generally reserved for large, symptomatic VSDs that cause congestive heart failure, pulmonary hypertension, or failure to thrive.
Choice C rationale
The prognosis following surgical repair of a VSD is generally excellent, with a low mortality rate. The outcome is highly dependent on the child's preoperative status, and most children have normal lives after successful repair.
Choice D rationale
Spontaneous closure of small muscular VSDs is a well-documented phenomenon. The closure is often attributed to muscular trabeculae growth and the formation of fibrous tissue around the defect. The likelihood of closure decreases with age.
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