A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Maintaining ambient room temperature at 24° C (75° F).

Drying the newborn's skin thoroughly.

Preventing air drafts.

Placing the newborn on a warm surface.

Answer and Explanation

The Correct Answer is B

A. Maintaining ambient room temperature at 24° C (75° F) can help prevent heat loss by keeping the environment warm, but it does not specifically address evaporative heat loss. Evaporative heat loss occurs when moisture on the skin evaporates, which is not directly controlled by ambient temperature.

B. Drying the newborn's skin thoroughly reduces evaporative heat loss by removing moisture that can evaporate and cool the skin. This action is critical immediately after birth when the newborn is wet with amniotic fluid.

C. Preventing air drafts helps reduce convective heat loss, not evaporative heat loss. Convective heat loss occurs when air moves across the skin and carries heat away.

D. Placing the newborn on a warm surface helps reduce conductive heat loss by preventing heat transfer from the baby to a cooler surface. However, this does not address evaporative heat loss, which is specifically related to moisture evaporation from the skin.

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Correct Answer is B

Explanation

Choice A rationale:

The nurse should not report the client's Hemoglobin level first to the primary health care because it falls within the normal range of 14 to 24 g/dL for a newborn. Therefore, it is not an immediate concern.

Choice B rationale:

The nurse should first report the client's Chest x-ray results to the primary health care. The diffuse pattern of radiopaque areas bilaterally on the chest x-ray suggests possible respiratory distress or other respiratory issues in the newborn. This finding requires immediate attention and intervention to ensure proper respiratory function.

Choice C rationale:

The nurse should not report the client's Glucose level first to the primary health care as 40 mg/dL is within the normal range of 30 to 60 mg/dL for a newborn. Though it is on the lower side, it is not critically low, and there are more urgent concerns to address.

A. Perform a sharp hand clap near the infant. B. Turn the newborn's head quickly to one side. C. Place a finger at the base of the newborn's toes. D. Hold the newborn vertically, allowing one foot to touch the crib surface.

Correct Answer is A

Explanation

Choice A rationale:

The Moro reflex, also known as the startle reflex, is a normal reflex observed in newborns. To elicit this reflex, the nurse should perform a sharp hand clap or make a loud noise near the infant. This reflex is characterized by the baby's arms and legs extending outward, followed by a quick flexion, resembling a startle response. It is an important reflex to assess the newborn's neurological and motor development.

Choice B rationale:

Turning the newborn's head quickly to one side does not elicit the Moro reflex. This action may stimulate other reflexes, such as the tonic neck reflex, but it is not the appropriate method to assess the Moro reflex.

Choice C rationale:

Placing a finger at the base of the newborn's toes does not elicit the Moro reflex. This action is more related to testing the Babinski reflex, which involves the fanning and curling of the toes when the sole of the foot is stimulated.

Choice D rationale:

Holding the newborn vertically and allowing one foot to touch the crib surface does not elicit the Moro reflex. This action might elicit the stepping reflex, where the baby shows stepping movements as if walking when held in an upright position with their feet touching a surface.

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A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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