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The nurse enters the room and notices that the room feels cold. The mother says, 'He has been crying and kicking and now he seems very tired.' What is the nurse's priority concern?
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. The infant is hungry.
- D. The infant is overstimulated.
Correct Answer: B
Rationale: A cold environment triggers nonshivering thermogenesis, burning brown fat, which can produce lactic acid, leading to metabolic acidosis.
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Which newborn is at the lowest risk for elevated unconjugated bilirubin levels?
- A. The newborn with significant bruising from a face presentation.
- B. The premature newborn.
- C. The baby born at 41 weeks' gestation.
- D. The newborn with O+ blood type, born to a mother with O- blood type.
Correct Answer: C
Rationale: A 41-week gestation newborn has a mature liver, minimizing bilirubin buildup compared to others with risk factors.
The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?
- A. Two hours since last eating.
- B. Temperature 36.2°C axillary on radiant warmer.
- C. Drying of the umbilical cord.
- D. Stable temperature for 2 hours.
Correct Answer: D
Rationale: Ensuring a stable body temperature for at least 2 hours is crucial before bathing to prevent hypothermia, as newborns are prone to heat loss.
A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?
- A. A newborn who is 8 hr old and has acrocyanosis.
- B. A newborn who is 18 hr old and has not voided.
- C. A newborn who is 24 hr old and has not passed meconium.
- D. A newborn who is 12 hr old and has an axillary temperature of 37.8°C (100° F).
Correct Answer: D
Rationale: A temperature of 37.8°C may indicate infection, requiring immediate assessment, unlike the other less urgent findings.
A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?
- A. The newborn's temperature control mechanism is immature.
- B. Heat increases the flow of oxygen to the newborn's extremities.
- C. The newborn has a small body surface for his weight.
- D. Heat facilitates the drainage of mucus for a premature newborn.
Correct Answer: A
Rationale: Premature newborns have immature thermoregulation, making an incubator essential to maintain body temperature and prevent cold stress.
A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 22/min.
- B. 100/min.
- C. 48/min.
- D. 110/min.
Correct Answer: C
Rationale: A respiratory rate of 48/min is within the normal newborn range (30-60/min), indicating healthy breathing.