An hour after birth, the nurse assesses a newborn's temperature ...

[jasdeep_brar]

An hour after birth, the nurse assesses a newborn's temperature and notes that it is 36.2 C (97.2 F). The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure.
 
  What is the nurse's next action?
 
  a. Take the infant's temperature rectally.
  b. Ask the father to test the water to determine if it is too hot.
  c. Delay the bath until the newborn's temperature is above 36.7 C (98 F).
  d. Explain to the new parents that no soap should be used to cleanse the eyes.

Question 2

A 38 weeks' gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery.
 
  Which is the priority nursing diagnosis?
 
  a. Risk for injury related to potential equipment malfunction of radiant warmer
  b. Altered tissue perfusion related to use of medications during delivery process
  c. Ineffective airway clearance due to mode of delivery and use of anesthetics
  d. Risk for ineffective thermoregulation related to gestational age

[jonathanballen97]

Answer to Question 1

ANS: C
A temperature of 36.7 C (98 F) or higher is often used to determine when to bathe the infant. The infant can lose heat in the bath through the process of evaporation. Rectal temperatures are avoided because they can traumatize the rectal mucosa. The water temperature should be approximately 38 to 40 C (100.4 to 104 F). The nurse and not the father needs to determine if the bath water is the correct temperature to avoid scalding the newborn. Explain the process of giving a bath during the procedure. Informing the parents before the procedure may result in loss of information.

Answer to Question 2

ANS: C
Delivery via cesarean section may affect the newborn's ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk for airway concerns. There is no evidence to support that the equipment is malfunctioning. Although the use of medications may affect the newborn in terms of respiratory, cardiac, and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is at term based on reported gestational age and therefore is not a risk for ineffective thermoregulation because of this fact.