The nurse is caring for a term infant immediately following delivery.Which action should the nurse implement to reduce the risk of cold stress?
Bathe the newborn in warm water and swaddle in 2 blankets.
Place the newborn on the radiant warmer.
Maintain a room temperature above 70° F (21.1° C).
Dry off the newborn and place skin-to-skin.
The Correct Answer is D
Choice A rationale
Bathing the newborn in warm water and swaddling in 2 blankets is not the best immediate action to prevent cold stress. While keeping the newborn warm is crucial, bathing immediately after birth can lead to rapid heat loss, and swaddling alone may not provide sufficient warmth.
Choice B rationale
Placing the newborn on a radiant warmer is an effective method to prevent cold stress, but it is not as beneficial as skin-to-skin contact, which provides both warmth and bonding. Radiant warmers are used primarily in situations where the infant requires stabilization or when skin-to-skin is not feasible.
Choice C rationale
Maintaining a room temperature above 70° F (21.1° C) helps to create a warmer environment, but it does not address the immediate need to prevent heat loss in the newborn. Room temperature alone may not be adequate to prevent cold stress, especially in preterm or low birth weight infants.
Choice D rationale
Drying off the newborn and placing them skin-to-skin with the mother is highly effective in preventing cold stress. This technique promotes thermal regulation through direct skin contact, which transfers body heat from the mother to the infant, stabilizes body temperature, and supports bonding and breastfeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Low back pain with pelvic cramping can indicate complications such as premature labor or an infection after an amniocentesis.
Choice A rationale
Increased fetal movement is not typically a sign of complications following amniocentesis and may be a normal finding.
Choice B rationale
Headache and blurred vision are concerning symptoms but are not directly related to amniocentesis complications.
Choice C rationale
Epigastric pain can be a sign of other issues, such as preeclampsia, but not specifically related to amniocentesis complications. .
Correct Answer is D
Explanation
Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.
Choice B rationale
Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.
Choice C rationale
Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.
Choice D rationale
Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.
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