A nurse is reinforcing teaching about newborn care with a client who is 2 hours postpartum.
Which of the following statements by the client indicates a need for further teaching?
"I will place my baby on my stomach and cover her with a warm blanket.”.
"My baby's temperature will be checked rectally every hour.”.
"I should keep my baby's head covered.”.
"My baby's bassinet should be kept away from fans and air conditioning.”.
The Correct Answer is B
Choice A rationale
Placing a newborn on the parent's stomach and covering with a warm blanket helps to regulate body temperature through skin-to-skin contact, which is essential for newborns, especially shortly after birth.
Choice B rationale
Rectal temperature checks are not recommended for newborns due to the risk of rectal perforation. Newborn temperatures are typically monitored using axillary (underarm) methods.
Choice C rationale
Keeping a newborn’s head covered helps to prevent heat loss, as a significant amount of body heat can be lost through the head. This practice is crucial in maintaining the newborn's body temperature.
Choice D rationale
Newborns should be kept away from drafts, including fans and air conditioning vents, to prevent them from becoming too cold. Keeping the bassinet away from these can help maintain a stable temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The primary role of the nurse in genetic counseling is to provide support and answer any Questions the client may have, helping them to understand the information and make informed decisions.
Choice B rationale
While discussing testing risks and benefits is important, it is usually the role of the genetic counselor or physician to explain these aspects comprehensively. The nurse supports this process but does not typically lead it.
Choice C rationale
Performing tests and analyzing results are tasks that are typically carried out by specialized laboratory personnel or geneticists, not the nurse. The nurse's role is supportive rather than diagnostic.
Choice D rationale
The nurse may assist during a provider's consult, but this is not the primary role. The main role focuses on supporting the client through the counseling process and ensuring they understand and can make informed decisions.
Correct Answer is C
Explanation
Choice A rationale
Initiating the Hypoglycemia Protocol is necessary when the blood sugar is <70 mg/dL to quickly raise blood glucose levels.
Choice B rationale
No insulin is administered when blood sugar levels are between 70-130 mg/dL as it is within the normal range.
Choice C rationale
Administering 2 units of insulin for blood sugar levels between 131-180 mg/dL helps lower glucose to the normal range.
Choice D rationale
Administering 4 units of insulin for blood sugar levels between 181-240 mg/dL is necessary to reduce hyperglycemia.
Choice E rationale
Administering 6 units of insulin for blood sugar levels between 241-300 mg/dL addresses more severe hyperglycemia.
Choice F rationale
Administering 8 units of insulin for blood sugar levels between 301-350 mg/dL is used to manage significant hyperglycemia.
Choice G rationale
Administering 10 units of insulin for blood sugar levels between 351-400 mg/dL is crucial for severe hyperglycemia.
Choice H rationale
Administering 12 units of insulin and calling the physician for blood sugar levels >400 mg/dL is critical for immediate medical intervention.
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