An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
chart the normal axillary temperature.
recheck the infant's temperature rectally.
place the infant in a radiant warmer.
have the mother breastfeed the infant.
The Correct Answer is C
Choice A reason:
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
Choice B reason:
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
Choice C reason:
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
Choice D reason:
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
This is incorrect because WIC does not provide immunizations for high-risk infants and children. Immunizations are provided by other health care services, which WIC may refer participants to.
Choice B reason:
This is incorrect because WIC does not screen for infants with developmental disorders. WIC provides nutrition education and referrals to other health and social services but does not diagnose or treat any medical conditions.
Choice C reason:
This is correct because WIC provides supplemental food supplies to low-income pregnant or breastfeeding women, as well as infants and children up to age 5 who are at nutritional risk. The food packages are designed to meet the special nutritional needs of the participants and include items such as fruits, vegetables, milk, cheese, cereal, bread, juice, peanut butter, eggs, and infant formula.
Choice D reason:
This is incorrect because WIC does not provide well-child examinations for infants and children living at the poverty level. WIC may refer participants to other health care services that provide such examinations but do not conduct them themselves.
Correct Answer is B
Explanation
The correct answer is choice B. Prolactin.
Choice A reason:
Estrogen. Estrogen is a hormone that plays a role in the development of the mammary glands and the ductal system during pregnancy. However, estrogen does not directly produce milk.
In fact, high levels of estrogen during pregnancy inhibit milk secretion by blocking prolactin. Therefore, estrogen is not the hormone necessary for milk production. • Choice B reason:
Prolactin. Prolactin is the hormone responsible for the production of breast milk. Prolactin is secreted by the pituitary gland in response to suckling or nipple stimulation. Prolactin levels rise during pregnancy and peak after delivery, when the sudden drop in estrogen and progesterone allows prolactin to take over and initiate lactation. Therefore, prolactin is the hormone necessary for milk production. • Choice C reason:
Progesterone. Progesterone is a hormone that also contributes to the development of the mammary glands and the alveoli during pregnancy. However, like estrogen, progesterone does not directly produce milk. Progesterone also inhibits milk secretion by blocking prolactin during pregnancy. Therefore, progesterone is not the hormone necessary for milk production. •
Choice D reason:
Lactogen. Lactogen is not a hormone, but a general term for any substance that stimulates lactation. There are different types of lactogens, such as human placental lactogen (hPL), which is produced by the placenta during pregnancy and has some lactogenic effects on the mammary glands. However, hPL is not the main hormone responsible for milk production. That role belongs to prolactin. Therefore, lactogen is not the hormone necessary for milk production.
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