The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?
Metabolic alkalosis.
Metabolic acidosis.
The infant is hungry.
The infant is overstimulated.
The Correct Answer is B
A. This condition typically results from excessive loss of acid, often due to vomiting or diuretics. It is not the most likely concern in a cold environment with an infant who has been crying and kicking.
B. A cold environment can lead to nonshivering thermogenesis in newborns, where they metabolize brown fat to generate heat. This process can lead to increased lactic acid production, potentially causing metabolic acidosis. The infant's fatigue following crying and kicking may indicate that the body has expended significant energy to stay warm, making metabolic acidosis a priority concern.
C. While hunger could be a reason for crying, it is not the priority concern in this scenario where environmental cold and fatigue are present.
D. Overstimulation might cause crying, but the environmental cold and subsequent risk of metabolic acidosis are more critical concerns in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
"This is a caput succedaneum, which is a collection of fluid from the pressure of the vacuum extractor.”.
Choice A rationale:
A Mongolian spot is a benign, flat, bluish-gray pigmented area often found on the sacral or gluteal area of some newborns with darker skin tones. It is not related to the swelling on the newborn's head caused by vacuum extraction.
Choice B rationale:
A caput succedaneum is a localized swelling on the baby's scalp that occurs due to pressure from the vacuum extractor during delivery. It is typically soft and may cross the suture lines. This explanation accurately describes the swelling the baby has on his head.
Choice C rationale:
Erythema toxicum is a common rash that appears as small red bumps with white or yellow centers. It is a benign and self-resolving condition that does not cause swelling on the head or involve the suture lines.
Choice D rationale:
A cephalhematoma is a collection of blood between the skull and the periosteum that does not cross the suture lines. It is caused by trauma during birth and may take weeks to months to resolve. This does not match the description of the swelling caused by vacuum extraction.
Correct Answer is ["A"]
Explanation
Choice A rationale:
The Moro reflex is a normal finding in newborns, including those born post-term. It is a primitive reflex that should be present and indicates a healthy neurological system.
Choice B rationale:
Vernix, a protective white substance that coats the skin in utero, is typically absent or minimal in post-term newborns due to its decreased production as gestation progresses. Therefore, it would not be expected in a post-term infant.
Choice C rationale:
Lanugo, the fine hair covering a newborn's body, is usually present in greater amounts in preterm infants. By the time a newborn is post-term, lanugo is typically sparse or absent, making it an unlikely finding.
Choice D rationale:
This maneuver assesses the flexibility of the newborn's joints. Post-term infants tend to have reduced flexibility and increased muscle tone, making this maneuver more difficult or restricted in this population.
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