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 Reason:
It is not necessary to avoid food and fluids the day of the procedure unless specifically instructed by the healthcare provider. Amniocentesis does not typically require fasting; however, some facilities may have different protocols.

Choice B Reason:
A bowel prep protocol is not required for an amniocentesis. This procedure is unrelated to the gastrointestinal tract, and bowel preparation is more commonly associated with procedures like colonoscopy.

Choice C Reason:
Emptying the bladder immediately prior to the procedure is important. A full bladder can obstruct the view of the uterus during ultrasound, which is used to guide the amniocentesis needle. Additionally, an empty bladder reduces the risk of accidental puncture during the procedure.

Choice D Reason:
Washing the abdomen with soap and water the morning of the procedure is a good hygiene practice but is not specifically required for amniocentesis. The area will be cleaned with antiseptic by the healthcare provider before the procedure.

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 teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

Correct Answer is C

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 instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?

A nurse is caring for a newborn delivered by vaginal birth with vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition?

A nurse is preparing to administer liquid mycostatin 600,000 units PO TID. Available is mycostatin 100,000 units/mL. How many m. should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

A nurse is preparing to administer methylergonovine IM to a client who has experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?