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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:
Initiating epidural anesthesia too soon may delay rupture of fetal membranes. This statement is not accurate. Epidural anesthesia itself does not have a direct impact on the rupture of fetal membranes. The timing of rupturing membranes is determined based on the progress of labor and other clinical indications. There is no causal relationship between epidural anesthesia and the timing of membrane rupture.

Choice B reason:
Initiating epidural anesthesia too soon can prolong labor. This statement is correct. Epidural anesthesia, while providing pain relief during labor, can also cause some degree of motor blockage and decrease the woman's ability to push effectively. This can potentially lead to a lengthening of the labor process. It is generally recommended to wait until a good labor pattern has been established to avoid unnecessary prolongation of labor.

Choice C reason:
Initiating epidural anesthesia too soon can cause fetal depression. This statement is not entirely accurate. Epidural anesthesia can cross the placenta and reach the fetus, but the effect on the baby is usually minimal. However, fetal monitoring is essential during labor to ensure the baby's well-being, regardless of whether epidural anesthesia is used or not.

Choice D reason:
Initiating epidural anesthesia too soon can cause maternal hypertension. This statement is not supported by evidence. Epidural anesthesia does not typically cause maternal hypertension. It can, however, lead to a decrease in blood pressure in some cases, which is why careful monitoring of maternal blood pressure is necessary during and after the administration of epidural anesthesia.

A. "I need to schedule the test when the baby is usually active.". B. "The baby's heart rate will be monitored during the test.". C. "I will have to lie on my back during the test.". D. "I will be able to go to the bathroom during the test as necessary.".

Correct Answer is C

Explanation

Choice A rationale:

The client's statement, "I need to schedule the test when the baby is usually active,”. is accurate and demonstrates a good understanding of the nonstress test (NST). The NST is typically performed to assess the baby's heart rate and movements when they are active, which provides better insights into the baby's well-being.

Choice B rationale:

The client's statement, "The baby's heart rate will be monitored during the test,”. is correct and indicates a solid grasp of the purpose of the NST. During the test, the baby's heart rate is continuously monitored to assess their overall well-being and any signs of distress.

Choice C rationale:

This is the correct answer. The client's statement, "I will have to lie on my back during the test,”. indicates a need for further teaching. In an NST, pregnant individuals are usually asked to lie on their left side, not on their back. The left lateral position enhances blood flow to the placenta and the baby, making it the preferred position for this test.

Choice D rationale:

The client's statement, "I will be able to go to the bathroom during the test as necessary,”. is accurate and demonstrates a good understanding of the NST procedure. Unlike some other prenatal tests, NST allows pregnant individuals to change positions, including using the bathroom if needed, to ensure their comfort during the monitoring process.

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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?

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Explanation

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Correct Answer is C

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