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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
An apical pulse of 130/min in a newborn is within the normal range. The normal heart rate for a newborn is generally between 110 to 160 beats per minute (bpm). As the newborn's heart rate falls within this range, the nurse should document it as an expected finding and continue routine monitoring.
Choice B rationale:
Calling the neonatologist to assess the newborn for an apical pulse of 130/min is not warranted as it is a normal finding. The nurse should only notify the neonatologist if there are abnormal vital signs or concerning clinical signs.
Choice C rationale:
Asking another nurse to verify the heart rate is unnecessary in this scenario. The nurse can independently measure the apical pulse and document the finding as long as it falls within the normal range for newborns.
Choice D rationale:
Preparing the newborn for transport to the Neonatal Intensive Care Unit (NICU) is not indicated for a normal apical pulse rate. Transporting a newborn to the NICU is typically reserved for critical or unstable conditions. In this case, the normal heart rate of 130/min does not warrant NICU transport.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.
Choice B rationale:
The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.
Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.
Choice D rationale:
The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.
Choice C rationale:
Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.
Choice E rationale:
The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.
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