A nurse is caring for a client who has just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?
Stimulate the infant to cry.
Clear the respiratory tract.
Dry the infant off and cover the head.
Cut the umbilical cord.
The Correct Answer is B
Choice A reason:
Stimulating the infant to cry is an important action as it helps ensure that the baby's lungs are clear of fluid and are functioning properly. However, this is not the first action to take. The initial cry will often occur naturally as part of the transition from intrauterine to extrauterine life.
Choice B reason:
Clearing the respiratory tract is the priority action. Immediately after birth, it is crucial to ensure that the newborn's airway is clear to facilitate breathing. The nurse may suction the mouth and nose to remove any amniotic fluid, mucus, or other obstructions that could impede breathing.
Choice C reason:
Drying the infant off and covering the head is important to prevent heat loss, which newborns are particularly susceptible to due to their large surface area relative to body mass. However, this follows the clearance of the airway, as maintaining an open airway is the most critical initial step in newborn care.
Choice D reason:
Cutting the umbilical cord is a necessary step in the delivery process, but it is not the first action to take when caring for the newborn. The timing of cord clamping can vary, and immediate care focuses on ensuring the newborn's ability to breathe effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Precipitous labor is characterized by a labor that progresses rapidly and ends within three hours of its onset. It is not typically associated with painless, bright red vaginal bleeding. This condition is more likely to present with intense, frequent contractions and a rapid change in cervical dilation. Therefore, precipitous labor is not the correct answer in this scenario.
Choice B reason:
Abruptio placentae, also known as placental abruption, is a condition where the placenta detaches from the uterus before delivery. It can cause significant maternal and fetal complications. The classic presentation includes painful bleeding, uterine tenderness, and contractions. Given that the scenario describes painless bleeding, abruptio placentae is less likely to be the correct diagnosis.
Choice C reason:
Placenta previa is a condition where the placenta covers the cervix partially or completely. The hallmark sign of placenta previa is painless, bright red vaginal bleeding, which aligns with the scenario provided. This bleeding can occur spontaneously or be triggered by intercourse or a medical exam. Placenta previa is a serious condition that can lead to maternal and fetal hemorrhage and warrants immediate medical attention. Based on the information provided, placenta previa is the most likely diagnosis for the client described.
Choice D reason:
Threatened abortion refers to vaginal bleeding that occurs in the first 20 weeks of pregnancy, which may indicate a potential miscarriage. Since the client is at 36 weeks gestation, threatened abortion is not a relevant diagnosis for late-term bleeding. Additionally, threatened abortion is often accompanied by abdominal cramping, which is not mentioned in the scenario.
Correct Answer is A
Explanation
Choice A reason:
Methylergonovine is used postpartum to prevent or control uterine bleeding by causing the uterus to contract. A firm fundus upon palpation indicates that the uterus is contracting well, which helps to compress the blood vessels and prevent excessive bleeding. This is the expected outcome when methylergonovine is effective.
Choice B reason:
The absence of breast pain is not directly related to the effectiveness of methylergonovine. Breast pain or engorgement typically occurs when milk comes in a few days postpartum and is not influenced by uterotonic medications.
Choice C reason:
An increase in lochia, or postpartum vaginal discharge, is not an indicator of methylergonovine's effectiveness. Lochia will naturally change and decrease as the postpartum period progresses and is not directly affected by the medication.
Choice D reason:
An increase in blood pressure is not an expected effect of methylergonovine and could indicate a side effect or complication. Methylergonovine can cause hypertension as a side effect, so an increase in blood pressure would warrant further assessment rather than indicating effectiveness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today