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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Delayed diaper changes can increase the risk of skin breakdown and infection.
B. Frequent repositioning and stimulation with a mobile may increase stress and intracranial pressure.
C. Minimizing stimulation, providing boundaries, and maintaining a calm environment (e.g., dim lighting) help reduce intracranial pressure and prevent further bleeding in infants with periventricular hemorrhage.
D. While pain management is important, feeding increases may exacerbate intracranial pressure and are not the priority.
Correct Answer is C
Explanation
A. The Ballard tool does not assess behavioral maturity directly.
B. The reflexes are part of the neuromuscular system, but the tool assesses both neuromuscular and physical maturity.
C. The Ballard assessment tool evaluates both neuromuscular maturity (such as posture, square window sign, arm recoil) and physical maturity (such as skin, ear form, breast tissue) in neonates to assess gestational age.
D. Reflexes are part of neuromuscular maturity, but the tool combines both neuromuscular and physical components.
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.