Which action should the nursery nurse take first in caring for the infant?
A) Dry the infant quickly with warm blankets.
Drying the infant is a priority to prevent evaporative heat loss.
B) Use a scale to immediately weigh the infant.
Weighing the infant can be delayed and another intervention done first.
C) Apply a servomechanism temperature probe.
Applying a temperature probe is a common procedure when using a radiant warmer; however, another action should come first.
D) Cover the infant's head using a soft cap.
Another action should be taken first.
After clearing the airway and drying the infant, the nurse assesses that the infant is breathing and has a heart rate of …show more content…
A functional heart murmur is a typical finding during the transition from fetal to newborn circulation.
B) Crepitus across right clavicle.
Crepitus could indicate a fractured clavicle that may have occurred at delivery.
C) Equal expansions of the chest.
Equal expansion of the chest is considered a normal finding.
D) Enlarged breasts with secretions.
Enlarged breasts with secretions are a normal variation in response to increased maternal hormones.
The infant exhibits a positive Babinski reflex.
Which action should the nurse take to elicit a Babinski reflex?
A) Stroke side of the sole of the foot from heel upward toward toes.
This will elicit the Babinski reflex with the newborn flexing the great toe and extending other toes, which is a normal response in an infant.
B) Hold newborn in supine position and allow head to drop backwards.
As the head drops about an inch this will elicit the Moro or startle reflex. With this reflex the infant initially abducts and extends the arms and legs, and then adducts and flexes the arms and legs.
C) Touch the newborn's cheek and observe for turning of the head toward the stimuli.
This approach elicits the rooting reflex, which helps the infant find food.
D) Turn the head to one side and observe the extension of the arm and leg on that side.
This approach elicits the tonic