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
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 B
Explanation
A. Maintaining ambient room temperature at 24° C (75° F) can help prevent heat loss by keeping the environment warm, but it does not specifically address evaporative heat loss. Evaporative heat loss occurs when moisture on the skin evaporates, which is not directly controlled by ambient temperature.
B. Drying the newborn's skin thoroughly reduces evaporative heat loss by removing moisture that can evaporate and cool the skin. This action is critical immediately after birth when the newborn is wet with amniotic fluid.
C. Preventing air drafts helps reduce convective heat loss, not evaporative heat loss. Convective heat loss occurs when air moves across the skin and carries heat away.
D. Placing the newborn on a warm surface helps reduce conductive heat loss by preventing heat transfer from the baby to a cooler surface. However, this does not address evaporative heat loss, which is specifically related to moisture evaporation from the skin.
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