After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
Wrap the newborn in a blanket.
Put a hat on the newborn's head.
Check the newborn's temperature.
Dry the newborn thoroughly.
The Correct Answer is D
A. Wrap the newborn in a blanket helps maintain body heat after the initial drying and stimulation but is not the first priority in thermoregulation.
B. Put a hat on the newborn's head also helps prevent heat loss, particularly from the head, which is a major site of heat loss in newborns. However, this should be done after drying to avoid trapping moisture.
C. Check the newborn's temperature is important but should be done after immediate measures to prevent heat loss have been taken.
D. Dry the newborn thoroughly is the first and most critical step in preventing evaporative heat loss, which is the primary cause of newborn heat loss immediately after birth. Removing wet amniotic fluid from the skin helps stabilize temperature effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Polyhydramnios refers to an excessive amount of amniotic fluid and typically presents with maternal discomfort, dyspnea, and possibly preterm labor, but not with vaginal bleeding as a primary symptom.
B. Placenta previa is the most likely diagnosis based on the assessment findings. It typically presents with painless, bright red vaginal bleeding in the second or third trimester, a soft, nontender uterus, no contractions, and a normal fetal heart rate. The bleeding may start spontaneously and often recurs. This fits the client's clinical picture precisely.
C. Placental abruption usually involves painful vaginal bleeding, a firm or tender uterus, and may be associated with uterine contractions or abnormal fetal heart rate patterns. The absence of pain and uterine tenderness in this case makes placental abruption less likely.
D. Ruptured ectopic pregnancy would not be expected at 33 weeks’ gestation. Ectopic pregnancies typically present in the first trimester and are accompanied by severe abdominal pain, vaginal bleeding, and signs of hypovolemic shock if ruptured.
Correct Answer is B
Explanation
A. Evidence that the newborn is becoming chilled would typically include signs such as cool skin, mottling, or acrocyanosis ,not active behaviors like head movement and eye contact.
B. A good time to initiate breast-feeding is correct. The described behaviors ,eye contact, head movement, and tongue thrusting, are characteristic of the first period of reactivity, which occurs within the first 30 minutes after birth. During this time, the newborn is alert, responsive, and exhibits strong rooting and sucking reflexes, making it an ideal window to begin breastfeeding.
C. The period of decreased responsiveness preceding sleep typically occurs after the first period of reactivity and is marked by reduced activity and interest in feeding, not alert behaviors.
D. A sign that the infant is being overstimulated would usually involve signs like gaze aversion, hiccupping, or flailing ,not purposeful movements or eye contact.
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