A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?
Confirm identification and apply a bracelet.
Examine the newborn for birth defects.
Dry the newborn.
Conduct a gestational age assessment.
The Correct Answer is C
The correct answer is choice c. Dry the newborn.
Choice A rationale:
Confirming identification and applying a bracelet is important for ensuring the newborn’s identity and preventing mix-ups, but it is not the immediate priority right after birth.
Choice B rationale:
Examining the newborn for birth defects is crucial for identifying any immediate health concerns, but it should be done after initial stabilization measures like drying and warming the newborn.
Choice C rationale:
Drying the newborn is the first action the nurse should take immediately after delivery. This helps to prevent heat loss and maintain the newborn’s body temperature, which is critical for their survival and well-being.
Choice D rationale:
Conducting a gestational age assessment is important for determining the newborn’s maturity and potential health risks, but it is not the immediate priority right after birth.
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Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Place the client in a knee-chest or Trendelenburg position.
Choice A rationale:
Preparing the client for an emergency cesarean birth is important, but it is not the immediate first action. The priority is to relieve pressure on the umbilical cord to prevent fetal hypoxia.
Choice B rationale:
Explaining to the client what is happening is important for communication and reassurance, but it is not the immediate first action. Immediate physical intervention is required to prevent harm to the fetus.
Choice C rationale:
Covering the cord with a sterile, moist saline dressing is a necessary step to prevent the cord from drying out and to reduce infection risk, but it should be done after repositioning the client to relieve pressure on the cord.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position helps to relieve pressure on the umbilical cord, which is crucial to maintain fetal oxygenation. This is the immediate first action to take in this emergency situation.
Correct Answer is ["A","B","E"]
Explanation
The correct answers are choices A. Blood pressure, B. Cerebral manifestations, and E. Deep tendon reflexes.
Choice A rationale:
Blood pressure is a critical parameter to monitor, especially in the third trimester. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate attention.
Choice B rationale:
Cerebral manifestations, such as headaches or visual disturbances, can also be signs of preeclampsia. These symptoms should be reported to the provider immediately.
Choice C rationale:
The fetal heart rate of 158/min is within the normal range (110-160 beats per minute) and does not need to be reported.
Choice D rationale:
The respiratory rate is not mentioned in the provided notes, and there is no indication that it is abnormal. Therefore, it does not need to be reported.
Choice E rationale:
Deep tendon reflexes that are hyperactive (3+) can be a sign of preeclampsia. This finding should be reported to the provider.
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