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 C

Explanation

A. While neonates are at higher risk for bleeding due to low vitamin K levels, the statement "neonates will hemorrhage without vitamin K" is too broad and not entirely accurate.
B. Breast milk is a poor source of vitamin K, which is why the injection is necessary.
C. Vitamin K is essential for the activation of clotting factors in the liver. Newborns are born with low levels of vitamin K, which is why they receive an injection to prevent bleeding.
D. Mothers do provide some vitamin K to the fetus through the placenta, but this is insufficient for the newborn after birth, necessitating the injection.

A. "Baby powder will help prevent a diaper rash." B. "I will use mild soap." C. "I will test the water on my wrist for temperature before bathing." D. "I will use a basin during bathing."

Correct Answer is A

Explanation

A. Baby powder should be avoided as it can be inhaled by the newborn, leading to respiratory issues.

B. Using mild soap is an appropriate practice for newborn care to avoid skin irritation.

C. Testing the water on the wrist of the caregiver’s hand before bathing minimizes the risk of burns,

D. Using a basin during bathing is an appropriate practice for newborn care.

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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

A client delivers a term neonate and expresses concern about the reason for giving the neonate a Vitamin K injection. Which information from the nurse is accurate?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?

A nurse completes a newborn assessment on a 6-hour-old newborn. She notices cyanotic hands and feet. Which action is the nurse's priority?

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?

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

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

The nurse knows that cardiopulmonary adaptation in the neonate involves five major changes; which includes the closure of which fetal cardiac structures?