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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Closing the door to the room. B. Placing crib near a warm wall. C. Warming equipment used on the neonate. D. Drying the neonate.

Correct Answer is D

Explanation

A. Closing the door reduces heat loss through convection, not evaporation.

B. Placing the crib near a warm wall reduces heat loss through radiation, not evaporation.

C. Warming equipment reduces heat loss through conduction, not evaporation.

D. Evaporation occurs when moisture on the newborn’s skin turns to vapor, causing heat loss. Drying the neonate immediately after birth and during baths is essential to prevent this.

View Question and Answer

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

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

Correct Answer is A

Explanation

Newborn heat loss through evaporation can be reduced by:

Correct Answer is D

Explanation

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

A 2-day old newborn is observed to be restless, irritable, sucking on its fist, and crying. What action should the nurse take first?

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?

A mother is concerned about her 3-day-old breastfeeding newborn whose birth weight was 2678g and is now 2505g. What is the most appropriate response by the nurse?

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?