A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Drying the newborn's skin thoroughly

Preventing air drafts

Placing the newborn on a warm surface

Maintaining ambient room temperature at 24° C (75" F)

Answer and Explanation

The Correct Answer is A

A.   Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B.   Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface helps prevent conductive heat loss.
D.   Maintaining ambient room temperature is important but does not directly address evaporative heat loss.

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Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

A. Fundus palpable to right of midline B. Less than 2.5 cm of rubra lochia on perineal pad C. Client report of increased thirst D. Client report of frequent uterine contractions

Correct Answer is A

Explanation

A. A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D. Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.

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A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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