Level: Clinical
Difficulty: Medium
Subtopic: Newborn transition
NCLEX: A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data include temperature 36.1°C (97°F) after the first bath. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that temperature 36.1°C (97°F) after the first bath.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that temperature 36.1°C (97°F) after the first bath.
Rationale
Correct answer: D. The new finding that temperature 36.1°C (97°F) after the first bath.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.