A nurse is assisting with the care of a client who is beginning the third stage of labor.
Which of the following actions should the nurse take first?
Check the newborn's axillary temperature.
Dry the newborn with clean towels.
Apply the identification bands to the newborn and the mother.
Allow private bonding time for the parents and newborn.
The Correct Answer is B
Choice A rationale
Checking the newborn's axillary temperature is important for thermoregulation, but immediate drying takes precedence to prevent heat loss through evaporation and convection. A stable temperature range for a newborn is typically 36.5°C to 37.5°C (97.7°F to 99.5°F). Hypothermia can lead to increased oxygen consumption and metabolic acidosis in newborns.
Choice B rationale
Drying the newborn immediately after birth is crucial for preventing evaporative heat loss. The wet surface of the newborn's skin, exposed to cooler ambient temperatures, can rapidly cool the infant through evaporation, leading to hypothermia. This is a primary intervention for neonatal thermoregulation.
Choice C rationale
Applying identification bands is a safety measure to prevent infant abduction or mix-up, but it is not the most immediate physiological need for the newborn after birth. While important, it can be done after ensuring the newborn's thermal stability.
Choice D rationale
Allowing private bonding time is beneficial for parent-infant attachment and can promote breastfeeding, but ensuring the newborn's physiological stability, particularly thermoregulation, takes precedence immediately after birth. Bonding can occur once initial assessments and interventions are completed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Combined estrogen-progestin contraceptive pills typically regulate the menstrual cycle and can often lead to shorter, lighter periods, or even amenorrhea in some individuals, due to the suppression of endometrial proliferation. The synthetic hormones, estrogen and progestin, stabilize the endometrium, preventing excessive build-up and subsequent heavy bleeding.
Choice B rationale
Medroxyprogesterone acetate (Depo-Provera) is an injectable contraceptive that provides long-acting contraception. It is administered intramuscularly or subcutaneously, but the typical administration frequency is once every 3 months (13 weeks), not once per month. This extended duration of action is due to the sustained release of the progestin.
Choice C rationale
Diaphragms are reusable barrier contraceptive devices. While a single diaphragm can be used for several years, it typically needs to be replaced every 1 to 2 years, or sooner if there is a significant weight change (gain or loss of 10-15 pounds), or after pregnancy, to ensure proper fit and contraceptive efficacy.
Choice D rationale
Oral contraceptives, particularly those containing estrogen and progestin, have been shown to significantly reduce the risk of endometrial cancer. This protective effect is primarily attributed to the progestin component, which counteracts the proliferative effects of estrogen on the endometrium, thereby preventing hyperplasia and subsequent malignant transformation.
Correct Answer is C
Explanation
Choice A rationale
Hyperglycemia in gestational diabetes typically leads to increased urination, or polyuria, not decreased urination. Elevated blood glucose levels overwhelm the renal tubules' reabsorption capacity, leading to glucose spilling into the urine, which then draws water osmotically, increasing urine output.
Choice B rationale
Shallow respirations are not a direct manifestation of hyperglycemia in this context. While severe diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, can lead to Kussmaul respirations (deep, rapid breathing) due to metabolic acidosis, hyperglycemia alone typically does not cause shallow respirations.
Choice C rationale
Thirst, or polydipsia, is a classic manifestation of hyperglycemia. High blood glucose levels increase the osmolality of the blood, stimulating osmoreceptors in the hypothalamus, which then trigger the sensation of thirst as the body attempts to dilute the excess glucose and restore fluid balance.
Choice D rationale
While hunger (polyphagia) is a common symptom in uncontrolled type 1 diabetes due to cellular inability to utilize glucose, in gestational diabetes with hyperglycemia, hunger is not a predominant or consistent symptom. The body typically has sufficient insulin, but there is insulin resistance or insufficient production.
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