The labor and delivery nurse is preparing for the delivery of their client's newborn infant.
The nurse brings a stack of warm blankets into the room and places them at the bedside.
Which statement by the nurse best educates the parents on why warm blankets are needed?
We will use the warm blankets to dry the baby which will help to prevent cold stress.
We will wrap the baby in warm blankets after delivery so that they will not shiver.
We will use the blankets to warm the baby's hands and feet to prevent acrocyanosis.
We will use the warm blankets only if the baby has a low temperature.
The Correct Answer is A
Newborn thermoregulation is critical due to their high surface area to mass ratio. Nurses must apply knowledge of heat loss mechanisms, specifically evaporation, to explain how drying the infant prevents cold stress, metabolic acidosis, and respiratory distress in the neonate.
Choice A rationale
Evaporation is the primary source of heat loss immediately after birth due to amniotic fluid. Drying the infant with warm blankets removes moisture, significantly reducing heat loss and preventing the cascade of physiological complications associated with neonatal cold stress.
Choice B rationale
Newborns possess limited ability to shiver for heat production, relying instead on nonshivering thermogenesis through brown fat metabolism. Wrapping them helps retain heat, but the rationale regarding shivering is physiologically inaccurate for the neonatal population during the immediate recovery.
Choice C rationale
Acrocyanosis, or bluish discoloration of hands and feet, is a normal vasomotor finding in the first 24 to 48 hours of life. It results from peripheral perfusion adjustments rather than strictly external temperature and does not require thermal intervention.
Choice D rationale
Prevention is the standard of care rather than reactive warming. Waiting for a low temperature, typically below 36.5 degrees Celsius or 97.7 degrees Fahrenheit, puts the infant at risk for hypoglycemia and increased oxygen consumption during thermogenesis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
This scenario involves preconception care and identifying reproductive risk factors. Knowledge of advanced parental age, recurrent pregnancy loss, and heritable genetic conditions is applied to determine which clients require specialized counseling to assess risks for chromosomal abnormalities or genetic disorders.
Choice A rationale
Advanced maternal age (≥ 35) and paternal age (≥ 40) increase the risk of chromosomal abnormalities like Down syndrome or new gene mutations. Counseling helps couples understand these statistical risks and available prenatal diagnostic testing options.
Choice B rationale
Macrosomia related to gestational diabetes is a metabolic and glycemic management issue rather than a primary genetic disorder. This clinical history does not typically warrant genetic counseling unless other risk factors for congenital anomalies are present.
Choice C rationale
Having a child with a congenital anomaly increases the risk of recurrence in subsequent pregnancies. Genetic counseling is essential to identify the inheritance pattern and provide the couple with specific risks for future children.
Choice D rationale
Recurrent pregnancy loss, defined as 3 or more miscarriages, may be caused by parental balanced translocations or other genetic factors. Investigation through counseling and karyotyping is recommended to identify the underlying cause of losses.
Choice E rationale
A family history of X-linked disorders, such as hemophilia or Duchenne muscular dystrophy, carries a specific inheritance risk. Counseling allows the client to understand the probability of passing the gene to their offspring.
Correct Answer is C
Explanation
The nurse must understand the physiological status of a newborns coagulation system and the role of intestinal flora. Knowledge of the mechanism of vitamin K synthesis and the prevention of Vitamin K Deficiency Bleeding is essential for this response.
Choice A rationale
Maternal diet is not the primary cause of newborn vitamin K deficiency. Even with a perfect maternal diet, vitamin K does not easily cross the placenta, leaving all newborns with low levels of the vitamin at birth.
Choice B rationale
This statement is scientifically incorrect because vitamin K actually promotes and is essential for the synthesis of prothrombin and other clotting factors in the liver. It does not prevent synthesis; it is a required cofactor for it.
Choice C rationale
Newborns have a sterile gut at birth, lacking the bacteria necessary to synthesize vitamin K. This deficiency impairs the production of clotting factors 2, 7, 9, and 10, significantly increasing the risk of life-threatening hemorrhagic disease.
Choice D rationale
Vitamin K is not needed for a full year via injection. Once the infant begins feeding and intestinal flora are established, they can synthesize their own vitamin K. The risk is highest during the first week..
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.