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 D

Explanation

Rationale:

A. Attempt to extinguish the fire before evacuating clients: The priority is client safety. Attempting to extinguish a fire should only be done if the fire is small, contained, and the area has been cleared. Evacuation takes precedence over suppression efforts.

B. Aim the spray of the fire extinguisher at the top of the fire: The correct technique is to aim at the base of the fire to effectively cut off the fuel source. Aiming at the top will not extinguish the fire and may waste the extinguisher’s contents.

C. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows can cause the fire to spread more rapidly by feeding it with oxygen. Doors should remain closed to help contain the fire and reduce the spread of smoke.

D. Have ambulatory clients walk independently to a safe location: Encouraging ambulatory clients to move independently helps prioritize assistance for those who are immobile or require more support. This approach ensures a quicker, safer evacuation process.

A. Start using a highchair for feedings B. Place no more than one small pillow in the crib C. Make sure the crib mattress is soft. D. Remove bibs when the infant is going to sleep.

Correct Answer is D

Explanation

Rationale:

A. Start using a highchair for feedings: Infants typically begin using a highchair around 6 months of age when they can sit unsupported. At 3 months, using a highchair is unsafe as the infant lacks sufficient head and trunk control.

B. Place no more than one small pillow in the crib: Pillows and soft bedding increase the risk of suffocation and sudden infant death syndrome (SIDS). The safest practice is to keep the crib free of pillows, blankets, and other soft items.

C. Make sure the crib mattress is soft: A firm crib mattress is recommended to reduce the risk of suffocation and SIDS. A soft mattress can create indentations that pose hazards for infants.

D. Remove bibs when the infant is going to sleep: Bibs can become choking or strangulation hazards during sleep. Removing them before sleep reduces the risk of airway obstruction and promotes infant safety.

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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?

Nursing Test Bank

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