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

While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.

Choice B rationale

Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.

Choice C rationale

Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.

Choice D rationale

Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.

A. Administer oxygen. B. Check cervical dilation. C. Start an intravenous fluid bolus. D. Prepare for immediate delivery.

Correct Answer is B

Explanation

Choice A rationale

Administering oxygen would not be the priority as the fetal heart rate is normal and there are no abnormal fetal movements or signs of distress. Oxygen administration is typically reserved for cases where there is evidence of fetal hypoxia or distress.

Choice B rationale

Checking cervical dilation is essential as it provides critical information about the progress of labor and helps in determining the next steps in management. It ensures that the labor is progressing appropriately and identifies if there is a need for any medical interventions.

Choice C rationale

Starting an intravenous fluid bolus would not be the first action in this scenario as the client does not show signs of dehydration or hypotension. Fluid bolus is generally reserved for cases where there is evidence of hypovolemia or to support hemodynamic stability.

Choice D rationale

Preparing for immediate delivery is not necessary at this stage as there are no signs of fetal distress or urgent complications. The client is only 37 weeks gestation and regular assessment is crucial to ensure timely and appropriate interventions without premature actions.

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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

A primigravida client is in the fourth stage of labor after the delivery of a newborn male infant.Which information should the nurse provide?

Correct Answer is C

Explanation

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?

Correct Answer is B

Explanation

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