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 ["A","B"]
Explanation
Choice A rationale
Performing a vaginal exam is crucial in assessing the progress of labor and the condition of the cervix, particularly if the client has reported symptoms such as contractions, bleeding, or fluid leakage. It helps determine if the client is in active labor or if there are any complications requiring immediate intervention.
Choice B rationale
Taking vital signs is essential to assess the client's overall health and identify any signs of distress or complications. Vital signs provide critical information about the client's cardiovascular and respiratory status, which is important for immediate clinical decision-making.
Choice C rationale
Palpating the bladder is important in assessing for bladder distention, which can impede labor progress or cause discomfort. However, it is not the immediate priority compared to assessing labor progress and overall health status.
Choice D rationale
Examining the amniotic fluid is important for determining its characteristics, which can provide information about the fetal well-being. However, this action is secondary to performing a vaginal exam and taking vital signs in the immediate assessment.
Choice E rationale
Dipstick urine for protein and ketones helps in assessing for preeclampsia or gestational diabetes, but it does not address the immediate need to assess labor progress and the client's overall health status.
Correct Answer is C
Explanation
Choice A rationale
Infusing 1,000 mL normal saline using a large bore IV is a good response to increase the client's blood volume and improve blood pressure, but it should not be the first action. The immediate priority is to relieve the compression of the inferior vena cava caused by the gravid uterus, which is decreasing blood return to the heart and causing hypotension.
Choice B rationale
Obtaining a blood sample for a complete blood count is important for assessing the client's overall health and identifying any possible complications, but it does not address the immediate life-threatening issue of hypotension caused by the gravid uterus compressing the inferior vena cava.
Choice C rationale
Tilting the backboard sideways to displace the uterus laterally is the correct first action. This maneuver helps to relieve the compression of the inferior vena cava by the gravid uterus, thereby improving blood return to the heart, increasing cardiac output, and normalizing blood pressure.
Choice D rationale
Palpating the abdomen for contractions is important to assess for potential labor or uterine irritability, but it does not address the immediate need to relieve the compression of the inferior vena cava causing hypotension.
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