The nurse is assessing a 40-week-gestation infant. What action by the nurse prevents heat loss through conduction?

Warm the stethoscope before use.

Move the infant away from a drafty vent.

Dry the infant with a towel.

Close the doors to the isolate.

Answer and Explanation

The Correct Answer is A

Choice A reason: Warming the stethoscope before use prevents heat loss through conduction. Conduction is the transfer of heat from the infant's body to a cooler surface or object that comes in direct contact with them. By warming the stethoscope, the nurse ensures that the infant does not lose heat to the cold surface of the stethoscope, thereby helping to maintain the infant's body temperature.

Choice B reason: Moving the infant away from a drafty vent helps prevent heat loss through convection, not conduction. Convection is the transfer of heat through air currents, and keeping the infant away from drafts helps minimize this type of heat loss.

Choice C reason: Drying the infant with a towel prevents heat loss through evaporation. When a wet infant is dried, it helps reduce the loss of heat that occurs as moisture evaporates from the skin.

Choice D reason: Closing the doors to the isolate helps prevent heat loss through radiation. Radiation is the transfer of heat from the infant's body to cooler surrounding surfaces. By closing the doors, the nurse helps maintain a warm environment, reducing heat loss.

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Correct Answer is B

Explanation

Choice A reason: Holding their head upright and sitting unsupported are signs that an infant may be ready for solid foods. These motor skills indicate that the baby has enough control to handle swallowing food safely.

Choice B reason: Pushing food out with their tongue is known as the tongue-thrust reflex, and it is a sign that the infant may not be ready for solid foods yet. This reflex prevents choking and generally diminishes between 4 and 6 months of age.

Choice C reason: Grasping small objects and not letting go demonstrates that the baby has developed fine motor skills, which are also important for starting solid foods. However, this alone does not determine readiness.

Choice D reason: Being between 4 and 6 months old is an appropriate age range for introducing solid foods, as long as other readiness signs are also present. Age alone is not the sole indicator of readiness for solid foods.

A. Lethargy and hypotonia B. Elastic skin turgor C. Apical heart rate 64 beats per minute D. Blood pressure = 100/54 mmHg E. Flat anterior fontanel

Correct Answer is C

Explanation

Choice A reason: Lethargy and hypotonia are concerning symptoms that indicate a significant decrease in muscle tone and alertness, which can be associated with various medical conditions. However, they may not require immediate intervention compared to a critically low heart rate.

Choice B reason: Elastic skin turgor is generally a normal finding, indicating good hydration status and skin elasticity. It does not require urgent attention.

Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a paediatric patient, indicating bradycardia. This requires immediate attention and intervention to ensure the patient's cardiovascular stability.

Choice D reason: A blood pressure of 100/54 mmHg is within a normal range for many paediatric patients and does not indicate an immediate emergency.

Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention.

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The nurse is assessing a 40-week-gestation infant. What action by the nurse prevents heat loss through conduction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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