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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale: Establishing IV access is necessary for potential fluid or blood replacement, but it is not the immediate priority over assessing the current physiological status of the fetus.

Choice B rationale: Monitoring the amount and color of vaginal bleeding is a vital assessment, but it does not provide direct information regarding the fetal response to the placental complication.

Choice C rationale: Assessing the fetal heart rate via external monitoring is the priority to ensure fetal well-being and detect distress, as the fetus is at high risk for hypoxia in placenta previa.

Choice D rationale: Glucocorticoids are administered to promote fetal lung maturity in anticipation of a preterm birth, but this intervention occurs after the initial assessment of fetal and maternal stability.

A. Cover the cord with a sterile, moist saline dressing. B. Place the client in the knee-chest position. C. Insert a gloved hand into the vagina to relieve pressure on the cord. D. Prepare the client for an immediate birth.

Correct Answer is B

Explanation

Choice A reason:
Covering the cord with a sterile, moist saline dressing can help to maintain the cord's viability by preventing drying and possible infection. However, this action does not address the immediate concern of relieving pressure on the cord to restore fetal circulation.

Choice B reason:
Placing the client in the knee-chest position is the most immediate and critical action to take. This position helps to relieve pressure on the prolapsed cord, which is vital to prevent compression of the cord and maintain blood flow to the fetus. It is a recommended emergency intervention for umbilical cord prolapse.

Choice C reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is a measure that may be taken by a healthcare provider in the event of a cord prolapse. However, it is not the first action to be performed. The initial step is to change the mother's position to relieve pressure on the cord.

Choice D reason:
Preparing the client for an immediate birth is necessary because umbilical cord prolapse is an obstetric emergency that requires prompt delivery, often by cesarean section, to prevent fetal hypoxia. However, the very first action is to relieve pressure on the cord to restore fetal oxygenation while preparations for delivery are made.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is the priority nursing action for a client at 33 weeks of gestation with a diagnosis of placenta previa?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Correct Answer is B

Explanation

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