A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1° C (97° F). Which of the following actions should the nurse take?
Apply a cap to the newborn's head.
Give the newborn a warm bath.
Reposition the newborn.
Obtain an oxygen saturation level.
The Correct Answer is A
A. Apply a cap to the newborn's head: This is an appropriate intervention to conserve heat in a mildly hypothermic newborn. It is a standard practice to maintain thermal neutrality, especially in the first hours after birth.
B. Give the newborn a warm bath: Bathing is not appropriate for a newborn with a low temperature. Bathing could worsen heat loss and further lower the newborn's body temperature.
C. Reposition the newborn: While repositioning may improve comfort or support effective respiration, it does not directly address the low temperature.
D. Obtain an oxygen saturation level: The respiratory rate (50/min) and heart rate (130/min) are within the normal range for a newborn. Unless other signs of respiratory distress or cyanosis are present, this action is unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,D,C,A
Explanation
The correct answer is choice B, D, C, A. B. Compress the bulb syringe: The nurse should first compress the bulb syringe to expel air from it. This ensures that when it is placed in the newborn’s mouth or nose, it can create suction to effectively remove mucus. D. Place the bulb syringe in the newborn's mouth: The nurse should then place the compressed bulb syringe into the newborn’s mouth first, as clearing the mouth is essential before the nose to prevent aspiration. C. Use the bulb syringe to suction the newborn's nose: After suctioning the mouth, the nurse should use the bulb syringe to suction the nose. Suctioning the nose after the mouth helps to clear the airway more effectively and reduce the risk of mucus being aspirated into the lungs. A. Assess the newborn for reflex bradycardia: After suctioning, the nurse should assess the newborn for any signs of reflex bradycardia, which can occur due to vagal stimulation during suctioning. This ensures the newborn's heart rate and overall well-being are monitored.
Correct Answer is A
Explanation
May 13. Nägele's Rule is used to calculate the estimated date of delivery (EDD) based on the first day of the last menstrual period (LMP). To use this rule, the nurse subtracts 3 months from the first day of the LMP and adds 7 days and 1 year.
For this client, the first day of her LMP was August 10. Subtracting 3 months gives us May 10. Adding 7 days gives us May 17. Adding 1 year gives us May 17, 2022. Therefore, the estimated date of delivery is May 17, 2022.
It is important to note that Nägele's Rule is an estimation, and not all pregnancies follow the typical 280-day gestational period. Other factors, such as irregular menstrual cycles, can affect the accuracy of the estimated date of delivery. The nurse should monitor the client's pregnancy and adjust the estimated date of delivery as needed based on ultrasound results and other clinical findings.
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