A nurse is caring for a newborn in the delivery room. Which of the following nursing actions is most effective in preventing heat loss via conduction?
Drying the newborn thoroughly and removing wet linens
Placing the newborn under a radiant warmer immediately after birth
Placing the newborn directly on the scale to obtain weight
Placing the newborn on a prewarmed blanket over the scale
The Correct Answer is D
A. Drying the newborn thoroughly and removing wet linens helps prevent evaporative heat loss, not conductive heat loss. While important for thermoregulation, this action does not directly address conduction, which occurs when the newborn comes into direct contact with a cooler surface.
B. Placing the newborn under a radiant warmer prevents heat loss through radiation, as the newborn absorbs heat from a warmer source without direct contact. This does not prevent conductive heat loss caused by touching cold surfaces.
C. Placing the newborn directly on the scale exposes the infant to cold, hard surfaces, which increases heat loss via conduction. This action would actually exacerbate conductive heat loss rather than prevent it.
D. Placing the newborn on a prewarmed blanket over the scale is the most effective way to prevent heat loss via conduction. Conduction occurs when heat is transferred from the newborn’s body to a cooler surface in direct contact. Using a prewarmed blanket provides insulation and prevents heat from transferring away from the infant, maintaining body temperature during initial assessments and procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This is not the priority. While monitoring blood glucose is important in certain situations (e.g., diabetic clients), absent deep-tendon reflexes indicate magnesium sulfate toxicity, which requires immediate intervention to prevent serious complications, making glucose assessment secondary.
B. This is not indicated. Trendelenburg position does not address magnesium sulfate toxicity or prevent its complications, and it is not part of the standard response to absent reflexes.
C. This action is unrelated. The client is postpartum, so cesarean birth is not relevant. The priority is maternal safety and management of magnesium toxicity, not delivery.
D. This is correct and is the first action. Absent deep-tendon reflexes indicate magnesium sulfate toxicity, which can progress to respiratory depression, cardiac arrest, and neuromuscular paralysis if not addressed. The nurse should stop the infusion immediately, notify the provider, and prepare to administer calcium gluconate as the antidote if ordered. Additional supportive measures include monitoring respiratory rate, oxygen saturation, urine output, and cardiac status.
Correct Answer is B
Explanation
A. Betamethasone is a corticosteroid given to enhance fetal lung maturity, typically when preterm birth is anticipated (<34–37 weeks). At 38 weeks gestation, the fetus is term, so corticosteroids are not indicated.
B. Hydralazine is an antihypertensive medication used to treat severe hypertension in pregnancy (systolic ≥160 mm Hg or diastolic ≥110 mm Hg). This client’s BP is 170/112 mm Hg, which meets criteria for immediate pharmacologic intervention to prevent maternal complications such as stroke, eclampsia, or organ damage. Therefore, the nurse should anticipate an order for hydralazine (or another antihypertensive like labetalol or nifedipine) to lower blood pressure safely.
C. Dexamethasone is also a corticosteroid used to promote fetal lung development and is not indicated at term gestation (38 weeks) for this client.
D. Lovenox (enoxaparin) is an anticoagulant used for thromboembolism prevention. While some pregnant clients may require anticoagulation, this client’s primary acute concern is severe hypertension, not clotting risk, making Lovenox inappropriate as the first intervention.
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