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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

"You can expect your breasts to be firm and tender 3 to 5 days after delivery." Postpartum care includes education on physical changes that occur after delivery. It is important for the nurse to inform the client that breast engorgement is a common occurrence and may result in firm, tender breasts 3 to 5 days after delivery. The nurse should also encourage the client to use a breast pump or express milk by hand to relieve discomfort. It is not advisable for the client to rely solely on breastfeeding as a form of birth control, so the nurse should educate the client on the importance of using contraception. Postpartum bleeding is typically bright red

A. A client who has preeclampsia and a creatinine level of 1.1 mg/dL B. A client who has placenta previa and a hematocrit of 36% C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has diabetes mellitus and an HbA1c of 5.8%

Correct Answer is C

Explanation

The correct answer is choice C, the client who has hyperemesis gravidarum and a sodium level of 110 mEq/L should be assessed first. This client's low sodium level indicates hyponatremia, which can lead to seizures and brain damage if not corrected promptly. The nurse should assess the client's neurologic status, including level of consciousness, reflexes, and motor function, and notify the provider immediately. The other clients also require close monitoring and intervention, but their conditions are not as urgent as the client with hyponatremia. Clients with preeclampsia require monitoring of blood pressure and kidney function, clients with placenta previa require monitoring of bleeding and hematocrit levels, and clients with diabetes mellitus require monitoring of blood glucose levels and HbA1c.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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