A nurse is caring for a client who just delivered a newborn.
Following the delivery, which nursing action should be done first to care for the newborn?

Dry the infant off and cover the head

Stimulate the infant to cry

Clear the respiratory tract

Cut the umbilical cord

Answer and Explanation

The Correct Answer is C

Choice A rationale

Drying the infant off and covering the head is important to prevent heat loss, but it is not the first action to be taken. The newborn’s body temperature can drop rapidly because of the evaporation of amniotic fluid, so drying the infant is a priority, but not the first one.

Choice B rationale

Stimulating the infant to cry is important as it helps to clear the lungs of amniotic fluid and promotes the expansion of the lungs for effective oxygenation. However, this is not the first action to be taken. The first action is to clear the respiratory tract.

Choice C rationale

Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly. This is done by suctioning the mouth first and then the nose to prevent aspiration of mucus or amniotic fluid, which can lead to respiratory distress.

Choice D rationale

Cutting the umbilical cord is done after the newborn’s respiratory status is stable. It is not the first action to be taken. The umbilical cord is usually clamped and cut by the healthcare provider after it has stopped pulsating, or after the newborn has started to breathe on their own.

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Correct Answer is A

Explanation

Choice A rationale

A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, it’s common for women to have difficulty emptying their bladder. If the bladder becomes too full, it can push the uterus to one side.

Choice B rationale

Frequent uterine contractions are not typically associated with a distended bladder. After childbirth, it’s normal for women to experience contractions as the uterus begins to shrink back to its pre-pregnancy size.

Choice C rationale

Increased thirst is not typically a sign of a distended bladder. It’s common for women to feel thirsty as their body adjusts after childbirth.

Choice D rationale

Less than 2.5 cm of rubra lochia on the perineal pad is not typically a sign of a distended bladder. Lochia is the vaginal discharge women experience after childbirth. It’s not related to bladder function.

A. Chadwick’s sign. B. Chvostek’s sign. C. Goodell’s sign. D. Cullen’s sign.

Correct Answer is D

Explanation

Choice A rationale

Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. This sign is commonly seen in early pregnancy, but it does not indicate the presence of blood in the peritoneum.

Choice B rationale

Chvostek’s sign is a clinical sign of existing nerve hyperexcitability seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. This sign is not related to a ruptured ectopic pregnancy.

Choice C rationale

Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascular softening is seen in early pregnancy. It does not indicate the presence of blood in the peritoneum.

Choice D rationale

Cullen’s sign is the appearance of bruising in the skin around the umbilicus. It occurs when there is blood in the peritoneum, or intra-abdominal bleeding. In the case of a suspected ruptured ectopic pregnancy, Cullen’s sign would indicate the presence of blood in the peritoneum.

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A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client’s bladder is distended?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is caring for a client who just delivered a newborn.
Following the delivery, which nursing action should be done first to care for the newborn?