The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to:
Select one:

Place the infant skin to skin with the mother and re-check temperature in 30 minutes.

Check the infant's CBC and blood cultures, as this is a sign of probable sepsis.

Return the infant to the nursery for close observation under warming lights.

Notify the physician immediately and suggest orders for placement in an incubator.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Place the infant skin to skin with the mother and re-check temperature in 30 minutes. This is because skin-to-skin contact is an eﬀective and safe method of increasing the infant's temperature and promoting thermoregulation. Skin-to-skin contact also has other benefits such as enhancing bonding, breastfeeding, and maternal-infant attachment.

Choice B Reason: Check the infant's CBC and blood cultures, as this is a sign of probable sepsis. This is an unnecessary action that may cause undue stress and discomfort to the infant and the mother. A slightly decreased temperature in a full-term infant is not a sign of probable sepsis, but rather a common finding that may be due to environmental factors, such as exposure to cold air or wet linens.

Choice C Reason: Return the infant to the nursery for close observation under warming lights. This is an undesirable action that may interfere with the early initiation of breastfeeding and bonding between the mother and the infant. Warming lights are not recommended for routine use in healthy newborns, as they may cause dehydration, hyperthermia, or eye damage.

Choice D Reason: Notify the physician immediately and suggest orders for placement in an incubator. This is an excessive action that may indicate a lack of knowledge or confidence on the part of the nurse. An incubator is not indicated for a stable, full term infant with a slightly decreased temperature, as it may expose the infant to unnecessary interventions, infections, or separation from the mother.

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Correct Answer is A

Explanation

Choice A Reason: Episodes of hypoglycemia and hyperglycemia. This is because episodes of hypoglycemia and hyperglycemia are common complications of diabetes during pregnancy, which can aﬀect both the mother and the fetus. Hypoglycemia is a condition where the blood glucose level drops below the normal range, which can cause symptoms such as sweating, trembling, hunger, confusion, or loss of consciousness. Hyperglycemia is a condition where the blood glucose level rises above the normal range, which can cause symptoms such as thirst, polyuria, fatigue, blurred vision, or ketoacidosis. Diabetes during pregnancy requires careful monitoring and management of blood glucose levels to prevent adverse outcomes such as fetal macrosomia, congenital anomalies, stillbirth, or neonatal hypoglycemia.

Choice B Reason: Postpartum hemorrhage. This is an incorrect answer that refers to a diﬀerent complication that may occur after delivery, not during pregnancy. Postpartum hemorrhage is excessive bleeding from the uterus or genital tract after delivery, which can cause hypovolemic shock, anemia, or death. Postpartum hemorrhage can be caused by uterine atony, retained placenta, lacerations, or coagulation disorders.

Choice C Reason: Cerebrovascular accident (CVA). This is an incorrect answer that indicates a rare and severe complication that may occur during or after pregnancy, not specifically related to diabetes. CVA is also known as stroke, which is an interruption of blood ﬂow to the brain due to ischemia or hemorrhage, which can cause neurological deficits or death. CVA can be caused by hypertension, preeclampsia-eclampsia, thrombophilia, or vascular malformations.

Choice D Reason: Acute vasospasm. This is an incorrect answer that suggests a diﬀerent condition that may occur during pregnancy, not associated with diabetes. Acute vasospasm is also known as Raynaud's phenomenon, which is a disorder of blood vessels that causes them to narrow and reduce blood ﬂow to the extremities in response to cold or stress, which can cause pain, numbness, or color changes. Acute vasospasm can be triggered by smoking, medications, or autoimmune diseases.

A. Possible Meconium Aspiration Syndrome (MAS). B. Possible polycythemia. C. Possible Transient Tachypnea of the Newborn (TTN). D. Possible Respiratory Distress Syndrome (RDS).

Correct Answer is D

Explanation

Choice A Reason: Possible Meconium Aspiration Syndrome (MAS). This is an unlikely condition for this newborn, as MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inﬂammation, and infection. MAS usually aﬀects term or post-term infants who experience fetal distress or hypoxia in utero.

Choice B Reason: Possible polycythemia. This is an unrelated condition for this newborn, as polycythemia refers to an abnormally high number of red blood cells in the blood, which can increase blood viscosity and impair circulation.

Polycythemia may occur in infants who have delayed cord clamping, intrauterine growth restriction, maternal diabetes, or high altitude exposure.

Choice C Reason: Possible Transient Tachypnea of the Newborn (TTN). This is a less serious condition than RDS, as TTN is a mild respiratory problem that results from delayed clearance of fetal lung ﬂuid after birth. TTN causes rapid breathing, nasal ﬂaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth.

Choice D Reason: Possible Respiratory Distress Syndrome (RDS). This is a serious condition that requires immediate intervention and treatment, as RDS can lead to life-threatening complications such as pulmonary hemorrhage, pneumothorax, or bronchopulmonary dysplasia. RDS causes respiratory distress, nasal ﬂaring, retractions, grunting, and central cyanosis. It usually occurs within minutes to hours after birth.

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The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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Select one: