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 A

Explanation

Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.

Choice B rationale

Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.

Choice C rationale

Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.

Choice D rationale

Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.

A. 37-weeks, 1-day. B. Pain rating of 5. C. Vaginal exam. D. Contractions every 3-4 minutes. E. A- blood type.

Correct Answer is A

Explanation

Choice A rationale

Being 37-weeks, 1-day gestation is considered term. This timing indicates the fetus is likely mature and ready for birth, which reduces the risk of complications compared to preterm delivery. However, early-term delivery can still have some associated risks, such as respiratory issues or feeding difficulties.

Choice B rationale

A pain rating of 5 during contractions is within the expected range during active labor. Pain management is an important aspect of labor care, but it does not inherently increase or decrease the risk of complications.

Choice C rationale

The vaginal exam findings of 4 cm dilation, 50% effacement, and -3 station indicate early labor progression. However, the negative station suggests the fetus is still high in the pelvis, which could pose a risk if labor stalls or if there is cephalopelvic disproportion.

Choice D rationale

Contractions every 3 to 4 minutes are consistent with active labor. Regular and moderate contractions are expected and necessary for labor to progress. This data point alone does not increase the risk for complications.

Choice E rationale

An A- blood type with Rh(D) immune globulin received at 28 weeks is managed appropriately to prevent Rh sensitization. Rh(D) immune globulin reduces the risk of hemolytic disease of the fetus and newborn in subsequent pregnancies, making it an important preventative measure but not a current risk factor. .

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is A

Explanation

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