The nurse is assessing a 4-hour old newborn. The nurse's findings include an irregular respiratory rate at 58, heart rate of 138 with a regular rhythm, and axillary temperature of 97.4 °F. Based on these assessments which intervention(s) should the nurse perform first?
Bring the baby to the nursery and place the baby underneath the warmer.
Start CPR on the baby using positive pressure ventilations.
Place the baby skin to skin with the mother.
Give the baby warmed oxygen by nasal cannula.
The Correct Answer is C
A. Placing the baby under a warmer can be done if skin-to-skin is not effective.
B. CPR is unnecessary as the newborn’s vital signs are within normal limits for this age.
C. Skin-to-skin contact is the best initial intervention to stabilize temperature and promote bonding, which may also regulate respiratory and heart rates.
D. Oxygen is not indicated as the respiratory rate and oxygenation appear adequate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Placing the baby under a warmer can be done if skin-to-skin is not effective.
B. CPR is unnecessary as the newborn’s vital signs are within normal limits for this age.
C. Skin-to-skin contact is the best initial intervention to stabilize temperature and promote bonding, which may also regulate respiratory and heart rates.
D. Oxygen is not indicated as the respiratory rate and oxygenation appear adequate.
Correct Answer is B
Explanation
A. Physiologic jaundice typically appears after 24 hours, not immediately.
B. Jaundice in the first 24 hours of life often indicates pathologic jaundice, frequently caused by blood group incompatibility (e.g., ABO or Rh incompatibility), leading to hemolysis and elevated bilirubin.
C. Vitamin K deficiency leads to bleeding disorders, not jaundice.
D. Maternal cocaine abuse is not directly linked to neonatal jaundice.
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