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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Flexion of all four extremities is a normal finding in newborns but does not specifically indicate successful transition to extrauterine life. It suggests good muscle tone, which is important, but vigorous crying is a more direct sign of effective respiratory effort and lung function.

Choice B rationale

A positive Babinski reflex is a normal reflexive response in newborns, indicating proper neurological function. However, it does not provide direct information about the newborn's respiratory or cardiovascular adaptation to life outside the womb.

Choice C rationale

Crying vigorously when stimulated is a strong indicator that the newborn is transitioning well to extrauterine life. It demonstrates that the infant's lungs are functioning properly, and they are capable of clearing airway secretions and maintaining adequate oxygenation, which are critical for survival outside the uterus.

Choice D rationale

A heart rate of 220 beats/minute is significantly higher than the normal range for newborns (120-160 beats/minute). Such tachycardia could indicate stress, dehydration, or underlying cardiac issues and does not reflect a normal transition to extrauterine life. .

A. Genital warts. B. German measles. C. Syphilis. D. Herpes simplex virus.

Correct Answer is D

Explanation

Choice A rationale

Genital warts, caused by human papillomavirus (HPV), typically present as small, flesh-colored or gray swellings in the genital area. They do not usually cause pain or vesicular lesions like those described. Genital warts may be flat or cauliflower-like in appearance but are generally distinct from the symptoms described in the question.

Choice B rationale

German measles (rubella) is a viral infection characterized by a red rash, mild fever, and swollen lymph nodes. It is not associated with vesicular lesions on the genital area. The virus primarily affects the respiratory system, and symptoms do not typically include shallow vesicles on the pubis, labia, and perineum.

Choice C rationale

Syphilis, caused by the bacterium Treponema pallidum, presents in stages. Primary syphilis manifests as a single sore (chancre), while secondary syphilis involves skin rashes and mucous membrane lesions. Tertiary syphilis can cause severe medical problems. The symptoms described do not align with any syphilis stage but rather suggest a different condition.

Choice D rationale

Herpes simplex virus (HSV) causes painful, shallow vesicles or ulcers in the genital area. HSV lesions are typically small, fluid-filled blisters that can rupture and form ulcers. The client's symptoms of shallow, small vesicles on her pubis, labia, and perineum are indicative of genital herpes.

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The nurse is caring for a term infant immediately following delivery.Which action should the nurse implement to reduce the risk of cold stress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth.Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is C

Explanation

A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes.The nurse observes several shallow, small vesicles on her pubis, labia, and perineum.The nurse should recognize the client is exhibiting symptoms of which condition?

Correct Answer is D

Explanation

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