A nurse is caring for a newborn who was just delivered at 35 weeks of gestation.
Click to highlight the action(s) the nurse should take to address each assessment finding. To deselect a nursing action, click the nursing action again
|
Assessment Findings |
Nursing Actions |
|
Body Temperature |
swaddle the newborn in a blanket dry the newborn monitor the newborn's vital signs place the newborn under radiant warmer |
|
Respiratory Status |
administer free-flow oxygen clear airway using bulb suction initiate chest compressions place the newborn in prone position |
swaddle the newborn in a blanket
dry the newborn
monitor the newborn's vital signs
place the newborn under radiant warmer
administer free-flow oxygen
clear airway using bulb suction
initiate chest compressions
place the newborn in prone position
The Correct Answer is ["A","B","C","D","E","F"]
Rationale for Correct Choices
• Swaddle the newborn in a blanket: Swaddling helps reduce heat loss through convection and evaporation, which is essential for a preterm newborn who has limited brown fat and poor thermoregulation. Maintaining warmth helps stabilize respiratory effort and metabolic demand. It is appropriate because the newborn’s temperature is below normal and continues to trend low.
• Dry the newborn: Drying reduces evaporative heat loss, which is a major risk immediately after birth, especially for late-preterm infants. Removing moisture from the skin supports temperature stabilization and reduces metabolic stress. This action is essential when temperatures remain below 36.5° C.
• Monitor the newborn’s vital signs: Frequent monitoring helps detect changes in temperature, heart rate, and respiratory drive, all of which can fluctuate rapidly in late-preterm newborns. Continuous monitoring allows the nurse to evaluate whether interventions for temperature and oxygenation are effective.
• Place the newborn under a radiant warmer: A radiant warmer provides controlled heat to support thermoregulation in preterm newborns who cannot maintain temperature independently. With temperatures at 36° C and 36.4° C, thermoregulation support is indicated to prevent cold stress. Radiant warming also helps stabilize oxygenation and metabolic rate.
• Administer free-flow oxygen: The newborn’s oxygen saturation is low at 90–91% on room air, indicating mild respiratory compromise. Providing free-flow oxygen improves oxygenation without requiring invasive airway management. This is appropriate for a newborn with increased respiratory effort but stable heart rate.
• Clear airway using bulb suction: Bulb suctioning is appropriate if secretions contribute to increased respiratory rate or difficulty maintaining saturation. Clearing the airway helps remove mucus that may impair airflow in preterm newborns. It supports spontaneous breathing and improves oxygenation.
Rationale for Incorrect Choices
• Initiate chest compressions: Chest compressions are only indicated when the newborn’s heart rate is below 60/min after at least 30 seconds of effective ventilation. This newborn’s heart rate is between 124–144/min, which is well above the threshold for resuscitation. Chest compressions are unnecessary and inappropriate for this clinical status.
• Place the newborn in prone position: Prone positioning is not recommended for routine stabilization and can compromise airway patency in a newborn requiring continuous monitoring. Supine or side-lying positioning reduces risk of airway obstruction and allows optimal chest expansion. Prone positioning increases risk for respiratory compromise in the acute period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Have you noticed a rash or reddening of your skin?": While skin irritation can occur with some occupational exposures, insulation installers are more commonly exposed to airborne fibers that affect the respiratory system rather than causing primary skin rashes.
B. "Do you have a cough or any breathing problems?": Insulation installers are at risk for inhaling fiberglass, asbestos, or other particles that can irritate the lungs and airways. Assessing for respiratory symptoms is essential to identify potential occupational lung disease or irritation.
C. "Have you noticed any loss of hearing or ringing in your ears?": Hearing loss and tinnitus are more relevant for workers exposed to loud noise, such as in manufacturing or construction environments with heavy machinery, rather than insulation installation specifically.
D. "Do you have any numbness or tingling in your fingers?": Numbness or tingling is usually associated with repetitive motion injuries, neuropathies, or exposure to vibrating tools. While possible, it is less directly related to the primary occupational hazards of insulation work.
Correct Answer is D
Explanation
A. The client drank 240 mL of water at 0800: This is objective data because it is a measurable and observable fact that can be verified by the nurse. Documentation of intake is based on direct observation rather than the client’s perception.
B. The client's gait is steady while using a walker: This is objective data as it is based on the nurse’s direct observation of the client’s physical performance. It can be measured or assessed without relying on the client’s personal experience.
C. The client cries while answering questions: Crying is an observable behavior, making it objective data. While it may indicate distress, the nurse is reporting what was seen rather than the client’s internal experience.
D. The client points to a 6 on the visual analog pain scale: This is subjective data because it reflects the client’s personal perception of pain, which cannot be independently measured or verified. Pain is inherently subjective, relying on the client’s self-report.
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