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","C","D"]

Explanation

A. Tachycardia: A compensatory response to cold stress as the infant tries to generate heat.
B. Shivering: Rare in newborns due to immature thermoregulation; not a common finding.
C. Hypoglycemia: Cold stress increases glucose consumption, risking hypoglycemia.
D. Lethargy: A late sign indicating worsening cold stress and potential hypothermia.
E. Hypertonia: Unrelated to cold stress, which more commonly causes hypotonia.

A. Entry of air into alveoli replacing the expelled amniotic fluid. B. Decreased oxygen levels after the cessation of placental blood flow. C. Upward movement of the diaphragm to create passive inspiration. D. Drying off and stimulating the newborn helps to trigger respiratory response.

Correct Answer is A

Explanation

A. The entry of air into the alveoli, replacing expelled amniotic fluid, is a critical mechanical stimulus that initiates the transition to neonatal breathing.
B. Decreased oxygen levels trigger chemical, not mechanical, stimuli.
C. The diaphragm moves downward during inspiration, not upward.
D. Drying and stimulation help initiate breathing through sensory stimulation, not mechanical.

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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 newborn is experiencing symptoms of cold stress. Which assessment data by the nurse will require further evaluation for stress protocol? (Select All that Apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse recognizes mechanical stimuli involved with the transition to extrauterine pulmonary function includes:

Correct Answer is A

Explanation

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