A nurse is contributing to the plan of care for a newborn who has a temperature of 36.4° C (97.5° F) at 1 hr after birth. Which of the following interventions should the nurse include?

Dress the newborn in a warm gown when placing them next to the parent's skin.

Delay the newborn's feedings until their temperature is stabilized.

Postpone the newborn's initial bath

Place the swaddled newborn under a radiant warmer.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Dress the newborn in a warm gown when placing them next to the parent's skin: Skin-to-skin contact, not clothing layers, is the priority for thermoregulation in the first hours after birth. A warm gown may interfere with skin contact and reduce the effectiveness of heat transfer from parent to newborn.

B. Delay the newborn's feedings until their temperature is stabilized: Early feeding is encouraged for newborns to promote bonding, glucose stabilization, and warmth. Feeding should not be delayed, as it can help the baby generate heat through metabolism.

C. Postpone the newborn's initial bath: A newborn’s bath should be delayed until their temperature is stable to prevent further heat loss. Bathing can cause evaporation-related cooling, which may worsen mild hypothermia in a newborn during the early hours of life.

D. Place the swaddled newborn under a radiant warmer: Swaddling under a radiant warmer interferes with direct heat transfer. The newborn should be unclothed (except for a diaper) under the warmer to ensure effective warming through radiation.

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Correct Answer is C

Explanation

Rationale:

A. Beefy, red tongue: A beefy, red tongue is typically associated with scarlet fever, not pertussis. It results from the streptococcal infection and accompanying inflammatory response, which is unrelated to the bacterial cause and symptom pattern of pertussis.

B. Productive cough with thick mucous: Pertussis, or whooping cough, usually causes a paroxysmal, dry, hacking cough followed by a characteristic "whooping" sound on inspiration. It is not commonly associated with a productive cough containing thick mucus, especially in early and peak stages.

C. Facial erythema: Facial erythema can occur during severe coughing fits in children with pertussis due to the forceful and prolonged nature of coughing episodes. The increased intrathoracic pressure during coughing may lead to flushing or redness of the face.

D. Koplik spots: Koplik spots are small, bluish-white lesions on the buccal mucosa and are an early sign of measles, not pertussis. They are not present in bacterial infections like Bordetella pertussis, which affects the respiratory tract.

A. "I will wait 1 hour after getting up in the morning to have breakfast." B. "I will try to eat balanced meals instead of only foods that appeal to my taste." C. “I will eat or drink something every 2 to 3 hours throughout the day" D. “I will eat a low protein snack 30 minutes before going to bed each night."

Correct Answer is C

Explanation

Rationale:

A. "I will wait 1 hour after getting up in the morning to have breakfast.": Delaying breakfast may worsen nausea, as symptoms of hyperemesis gravidarum are often worse in the morning. It is recommended to eat a small, dry carbohydrate-rich snack, such as crackers, soon after waking.

B. "I will try to eat balanced meals instead of only foods that appeal to my taste.": While balanced meals are ideal, during hyperemesis gravidarum, the priority is tolerating any nutrition. Clients are encouraged to eat whatever foods they can tolerate, as nutritional intake is often severely limited.

C. “I will eat or drink something every 2 to 3 hours throughout the day": Eating or drinking small amounts frequently helps prevent an empty stomach, which can trigger or worsen nausea and vomiting. This approach improves tolerance and supports hydration and nutrition.

D. “I will eat a low protein snack 30 minutes before going to bed each night.": Protein-rich snacks, not low-protein ones, are better for stabilizing blood glucose levels overnight and may help reduce morning nausea. A high-protein snack before bed is more appropriate.

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A nurse is contributing to the plan of care for a newborn who has a temperature of 36.4° C (97.5° F) at 1 hr after birth. Which of the following interventions should the nurse include?

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