When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
A.
Hypothermia.
B.
Deficient fluid volume.
C.
Impaired gas exchange.
D.
Risk for infection.
The correct answer and Explanation is :
The correct answer is A. Hypothermia.
In the scenario, the newborn’s axillary temperature is 95.8° F (35.4° C), which indicates hypothermia. Normal axillary temperature for a newborn typically ranges between 97.7°F (36.5°C) and 99.5°F (37.5°C). A temperature below this range signals that the newborn is experiencing hypothermia, which can be a serious condition that requires immediate attention.
Newborns are particularly vulnerable to hypothermia because they have a high surface area-to-body weight ratio, limited subcutaneous fat, and immature temperature regulation systems. They lose heat more rapidly than adults, especially in the first few hours after birth. If not corrected promptly, hypothermia can lead to cold stress, metabolic acidosis, hypoglycemia, and impaired oxygenation.
While the pulse rate of 114 beats per minute and respiratory rate of 60 breaths per minute are within acceptable ranges for a newborn (normal heart rate: 110–160 bpm, normal respiratory rate: 30–60 breaths per minute), the low body temperature is concerning. In a cold-stressed newborn, the body compensates by increasing oxygen consumption and metabolism to generate heat, which can lead to complications like hypoxia and respiratory distress. Thus, addressing hypothermia promptly can help prevent further physiological derangements, including impaired gas exchange or fluid imbalances.
Interventions for hypothermia in a newborn include warming the infant through skin-to-skin contact with the mother, placing the baby under a radiant warmer, or using warm blankets to raise body temperature. Continuous monitoring of temperature and other vital signs is critical in ensuring the infant stabilizes.
Therefore, in this situation, hypothermia should be the nurse’s priority concern.