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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Colostrum, the first form of breast milk, is produced in small amounts and is rich in nutrients and antibodies. Many new mothers are unaware of this and need reassurance.
B. Formula is not necessary unless medically indicated or the mother persists after being educated.
C. Donor breast milk is typically reserved for medically fragile infants.
D. Burping after feeding is important but does not address the client’s concern about milk supply.

A. Hemolysis of neonatal red blood cells by the maternal antibodies. B. Delayed meconium excretion resulting in the production of direct bilirubin. C. Pathological liver function resulting from hypoxemia during the birthing process. D. Physiological destruction of fetal red blood cells during the extrauterine period.

Correct Answer is D

Explanation

A. Hemolysis by maternal antibodies suggests hemolytic disease of the newborn (e.g., Rh incompatibility), which typically presents earlier and more severely.
B. Delayed meconium excretion may lead to increased bilirubin, but this is not the most common cause of jaundice at 3 days.
C. Pathological jaundice occurs within the first 24 hours or persists longer than a week.
D. Physiological jaundice is a common finding in newborns due to the natural breakdown of fetal red blood cells (RBCs) and the immature liver's inability to efficiently process bilirubin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 1-day postpartum client that is breastfeeding a healthy full-term newborn. The client requests a bottle of formula and verbalizes that she does "not have any milk". What is the most appropriate response?

Correct Answer is A

Explanation

A 3-day-old infant is slightly jaundiced and has an elevated bilirubin level. What is the most probable cause for these changes?

Correct Answer is D

Explanation

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