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
Explanation
The client who is at 34 weeks of gestation and is experiencing epigastric pain and headache should be assessed first. These symptoms may indicate preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and organ damage. The nurse should monitor the client's blood pressure and assess for signs of organ damage, such as proteinuria, visual disturbances, and epigastric or right upper quadrant pain. The other clients may also require assessment and intervention, but their symptoms are less urgent and may indicate less serious conditions, such as a urinary tract infection (painful urination), early pregnancy symptoms (nausea and vomiting), or early labor (cramping and spotting).
Correct Answer is B
Explanation
Answer and explanation
A. Decreased maternal hormones during pregnancy might affect fetal development, but it is not directly linked to the assessment finding of flat areola with no bud in a newborn.
B. Preterm gestational age is the most likely condition indicated by the finding of flat areola with no bud. Breast tissue development in newborns correlates with gestational age. In preterm infants, the breast tissue is often less developed, resulting in a flat areola without a bud.
C. Ambiguous secondary sex characteristics refer to physical traits that do not distinctly fit typical definitions of male or female. The described finding of flat areola with no bud is a specific developmental feature rather than a characteristic of ambiguous secondary sex traits.
D. Congenital anomalies are structural or functional abnormalities present at birth, but the described finding of flat areola with no bud is more indicative of prematurity rather than a congenital anomaly.
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