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 D

Explanation

The correct answer is choice D: Document the findings and continue to monitor the client.

Rationale:

Choice A: While encouraging the client to empty her bladder is important to help with uterine contraction, it's not the priority in this situation. The client's fundus is firm and midline, indicating good uterine contraction.

Choice B: Increasing the frequency of fundal massage is not necessary when the fundus is firm and midline. Excessive fundal massage can lead to uterine fatigue and decreased contractility.

Choice C: Notifying the client's provider is not necessary for a moderate amount of lochia rubra and small clots in the early postpartum period. This is a normal finding.

Choice D: Documenting the findings and continuing to monitor the client is the correct action. The nurse should document the amount, color, and consistency of lochia, as well as the fundus assessment. The client should be monitored closely for any signs of excessive bleeding or uterine atony.

A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. B. Monitor vital signs during admission of a client who has gestational hypertension. C. Change the perineal pad of a client who just transferred from labor and delivery. D. Observe an area of redness on the breast of a client who is 1 day postpartum.

Correct Answer is C

Explanation

Choice A reason:
Providing a sitz bath to a client with a fourth-degree laceration is a task that requires clinical judgment and skill to assess the healing process and manage potential complications. This task should not be delegated to an AP as it falls outside their scope of practice.

Choice B reason:
Monitoring vital signs during the admission of a client with gestational hypertension involves assessment and interpretation of data to detect potential complications. This is a nursing responsibility and should not be delegated to an AP, as it requires clinical judgment and knowledge of gestational hypertension.

Choice C reason:
Changing the perineal pad of a client who just transferred from labor and delivery is a task that can be delegated to an AP. This task does not require the AP to make assessments or clinical judgments, which makes it appropriate for delegation. The nurse should ensure that the AP has been trained and is competent in performing this task.

Choice D reason:
Observing an area of redness on the breast of a client who is 1 day postpartum involves assessment skills to determine if the redness is indicative of an infection or other complication. This task should not be delegated to an AP, as it requires clinical judgment and knowledge of postpartum complications.

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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

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the level of the umbilicus. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is C

Explanation

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

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A nurse is providing teaching to the mother of a newborn born small for gestational age (SGA). Which of the following should the nurse include as a possible cause of this condition?