NUR 230 Maternal Exam 2 | Galen College of Nursing

NUR 230 Maternal Exam 2 | Galen College of Nursings 1. The nurse is assessing physiological changes in a newborn. Which of the following is the priority concern? A. Successful feeding B. Thermoregulation C. Extra-uterine circulatory transition D. Spontaneous respirations Correct Answer: B Rationale: Newborns are at high risk for cold stress due to large body surface area, thin skin, limited subcutaneous fat, and immature thermoregulation. Cold stress increases oxygen consumption and can lead to hypoglycemia and metabolic acidosis. Maintaining a neutral thermal environment is a top priority immediately after birth (AAP Newborn Care Guidelines). 2. The nurse is caring for a newborn immediately after birth. Which intervention is most important to prevent heat loss? A. Place a hat on the infant’s head B. Utilize a clear plastic wrap or radiant warmer C. Bathe the infant within the first 30 minutes D. Encourage skin-to-skin contact only after the bath Correct Answer: B Rationale: Evaporative heat loss is rapid in the first minutes of life. Using plastic wrap or a radiant warmer immediately after drying the infant is the most effective initial intervention to prevent hypothermia (AWHONN and AAP standards). 3. A newborn has an axillary temperature of 36.2°C (97.2°F) one hour after birth. The nurse recognizes this as: A. A normal variation B. Cold stress requiring immediate intervention C. Expected due to maternal medications D. An early sign of sepsis Correct Answer: B Rationale: Normal newborn temperature is 36.5–37.5°C. A temperature below 36.5°C indicates cold stress, which must be treated promptly to prevent increased metabolic demand, hypoglycemia, and respiratory distress. 4. A full-term newborn is jittery with a blood glucose of 38 mg/dL at 2 hours of age. The nurse’s first action is to: A. Administer glucagon IM B. Initiate skin-to-skin contact and encourage breastfeeding C. Start an IV dextrose bolus D. Notify the provider for insulin