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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Covering the cord with the diaper can create a moist environment that promotes bacterial growth and delays healing.
Choice B rationale
Washing the cord daily with mild soap and water is not recommended. It’s better to keep the cord dry and clean.
Choice C rationale
Applying petroleum jelly to the cord stump is not advised. It can create a moist environment that can delay the drying and falling off of the stump.
Choice D rationale
Giving a sponge bath until the cord stump falls off is the correct instruction. This prevents the stump from getting wet, which can delay healing and increase the risk of infection.
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting after feedings is a classic symptom of pyloric stenosis. This occurs because the enlarged pyloric muscle obstructs the passage of food from the stomach to the small intestine.
Choice B rationale
Absent bowel sounds are not typically associated with pyloric stenosis. While this condition affects the gastrointestinal tract, it does not typically cause a complete absence of bowel sounds.
Choice C rationale
Increased sodium levels are not a typical finding in a newborn with pyloric stenosis. In fact, these infants may have low sodium levels due to vomiting.
Choice D rationale
A golf ball-sized mass over the left quadrant is not a typical finding in a newborn with pyloric stenosis. The classic physical examination finding in pyloric stenosis is a palpable “olive-like” mass in the right upper quadrant of the abdomen.
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