Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).
Respiratory distress.
Hyperglycemia.
Metabolic alkalosis.
Hypoglycemia.
Correct Answer : A,D
Choice A rationale:
Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.
Choice B rationale:
Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.
Choice C rationale:
Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.
Choice D rationale:
Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.
Choice E rationale:
Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rooting. Choice A rationale:
The Moro reflex is a startle reflex characterized by the infant's sudden extension and abduction of the arms in response to a loud noise or sudden movement. It is not involved in the initiation of sucking and is unrelated to breastfeeding.
Choice B rationale:
The rooting reflex is a crucial reflex that helps initiate sucking in newborns. When the infant's cheek is stroked or touched, they will turn their head toward the stimulus and open their mouth, preparing for feeding. This reflex helps the infant find the mother's nipple and begin breastfeeding effectively.
Choice C rationale:
The stepping reflex is a primitive reflex observed in newborns when held upright with their feet touching a solid surface. The baby will make stepping movements, mimicking walking. However, this reflex is not related to the initiation of sucking and breastfeeding.
Choice D rationale:
The Babinski reflex is a reflex in which the big toe extends upward and the other toes fan out when the sole of the foot is stimulated. This reflex is present in newborns and disappears as the child grows older. It is not involved in the initiation of sucking.
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale:
The newborn reflex called "rooting”. is characterized by turning the head and opening the mouth when the cheek or mouth area is touched. This reflex helps the newborn find the mother's breast for feeding.
Choice B rationale:
"Stepping”. is a newborn reflex where they make stepping movements when held upright with their feet touching a solid surface. This reflex is present at birth but tends to disappear after a few weeks.
Choice C rationale:
The "Moro”. reflex is also known as the startle reflex. It is elicited by a sudden loss of support or loud noise, causing the newborn to throw their arms and legs out and then bring them back in. This reflex usually disappears around 3 to 4 months of age.
Choice D rationale:
The "Babinski”. reflex is characterized by the extension of the big toe and fanning of the other toes when the sole of the foot is stroked. This reflex is present in newborns and should disappear by around 12 months of age.
Choice E rationale:
"Running”. is not a recognized newborn reflex. There is no reflex with this name related to newborns.
Choice F rationale:
The "gag”. reflex is present in newborns and helps protect the airway by causing a gagging response when the back of the throat is stimulated.
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