A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Stimulate the infant to cry.

Clear the respiratory tract.

Dry the infant off and cover the head.

Clamp the umbilical cord.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Stimulate the infant to cry. While stimulating the infant to cry is a common practice to assess the newborn's respiratory function, it is not the first action the nurse should perform in this situation. The newborn may cry spontaneously or may require other interventions, such as clearing the respiratory tract, before crying.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract is the priority action in this scenario. It ensures that the airway is open and allows the infant to breathe effectively. This is crucial because newborns are at higher risk of respiratory distress after birth, and prompt action can prevent complications.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head are important steps to prevent heat loss and maintain the newborn's body temperature. However, these actions can be delayed briefly until the respiratory tract is cleared, as the immediate focus should be on ensuring the infant's ability to breathe.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is a standard procedure after birth to prevent bleeding and infection. However, it is not the priority in this situation. The first step should be to ensure the newborn's airway is clear and they can breathe adequately.

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Correct Answer is C

Explanation

Choice A rationale:

A fetal heart rate of 100/min for a 10-minute period is considered within the normal range. The normal fetal heart rate can range from 110 to 160 beats per minute, and a rate of 100 is not concerning.

Choice B rationale:

The resting period of a contraction refers to the time between contractions when the uterus is relaxed. A resting period of 35 seconds is also considered normal. In labor, the resting period between contractions allows the placenta to receive oxygen and nutrients, and 35 seconds is a rationaleable duration.

Choice C rationale:

A contraction lasting 85 seconds is abnormal and should be reported to the provider. Normally, contractions last around 60-90 seconds, but an 85-second contraction may indicate uterine hyperactivity or other issues that could potentially affect the well-being of both the mother and the baby.

Choice D rationale:

Having four contractions in a 10-minute period is considered normal during labor. In fact, an average pattern includes 3-5 contractions within a 10-minute window, so this finding is not a cause for concern.

A. This test determines the estimated date of birth. B. The client will need to be NPO for 8 hr prior to the test. C. The nurse will initiate an IV prior to this test. D. The test predicts fetal well-being in the third trimester.

Correct Answer is D

Explanation

Choice D rationale:

The correct answer is Choice D. The biophysical profile is a prenatal test used to assess fetal well-being in the third trimester of pregnancy. It is not used to determine the estimated date of birth (Choice A), as that is typically calculated based on the first day of the last menstrual period and confirmed or adjusted by early ultrasounds.

The test also does not require the client to be NPO (nothing by mouth) for 8 hours prior to the test (Choice B). This restriction is commonly associated with certain medical procedures, but it is not applicable to the biophysical profile.

Furthermore, there is no need to initiate an IV (intravenous line) before the biophysical profile (Choice C). The test is non-invasive and involves the use of ultrasound and fetal heart rate monitoring. The biophysical profile assesses several fetal parameters, such as fetal movement, fetal tone, fetal breathing movements, amniotic fluid volume, and the fetal heart rate. These parameters help evaluate the well-being and health of the baby. The test is often recommended in cases of high-risk pregnancies, decreased fetal movement, or other conditions that may warrant closer monitoring of the baby's condition. By knowing that the biophysical profile predicts fetal well-being in the third trimester, the nurse can provide accurate information to the client, reassuring them about the health of their baby and explaining the importance of the test in ensuring a safe delivery and healthy outcome.

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A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in labour. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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