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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Painless, bright red vaginal bleeding at 36 weeks gestation is indicative of placenta previa. Placenta previa is a condition in which the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to efface and dilate. The bright red color of the blood is due to its fresh origin from the exposed placental vessels. This condition is painless because the bleeding occurs without uterine contractions.
Choice B rationale:
Preterm labor is not the correct answer in this scenario. Preterm labor refers to the onset of regular uterine contractions leading to cervical changes before 37 weeks of gestation. In this case, the key indicator is painless bleeding, which is not associated with uterine contractions.
Choice C rationale:
Threatened abortion is also not the correct answer. Threatened abortion is the term used when a pregnant woman experiences vaginal bleeding, but the cervix is closed, indicating that there is still a chance for the pregnancy to continue. However, the bleeding in placenta previa is unrelated to fetal viability and is specifically caused by the placental position.
Choice D rationale:
Abruptio placentae is not the correct answer either. Abruptio placentae, also known as placental abruption, is a condition where the placenta prematurely separates from the uterine wall before delivery. This can cause painful bleeding due to the blood being trapped between the placenta and uterine wall. In the given scenario, the bleeding is described as painless, which does not align with the characteristics of abruptio placentae.
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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