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.

None

Answer and Explanation

The Correct Answer is C

This action is important as it helps to prevent hypothermia, which newborns are particularly susceptible to. However, while drying the infant is essential, it should not be the very first action taken immediately after birth.

Stimulating the infant to cry can help establish normal respiratory function and is important for transitioning to extrauterine life. However, it may not be the first action if the infant is not breathing or appears to need immediate airway clearance.

This is a critical first step, especially if the newborn is not breathing adequately. Clearing the airway (using suction if necessary) is vital to ensure that the infant can breathe properly and transition well after birth. If there are any signs of airway obstruction or if the infant is not crying, this action takes precedence.

While cutting the umbilical cord is a standard procedure, it is typically performed after ensuring the infant is stable. Current guidelines suggest delaying cord clamping for a short period unless there are complications that require immediate action.

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Correct Answer is A

Explanation

Late decelerations on the fetal monitor tracing indicate uteroplacental insufficiency, which can compromise fetal oxygenation. When membranes rupture and late decelerations occur, it's essential to take immediate action to improve fetal oxygenation.
Turning the client onto her side can help improve uteroplacental perfusion by relieving pressure on the vena cava and increasing blood flow to the uterus. This is the initial recommended intervention to optimize fetal oxygenation in the presence of late decelerations.
B. Increasing IV fluid infusion rate may be considered to optimize maternal hydration and potentially improve uteroplacental perfusion. However, it may not be the first action taken in response to late decelerations.
C. Palpating the client's uterus can provide information about uterine activity and may help assess for uterine hyperstimulation, which can contribute to fetal distress. However, in the context of late decelerations, the priority is to address potential uteroplacental insufficiency and optimize fetal oxygenation.
D. Administering oxygen to the client helps increase maternal oxygenation, which in turn improves fetal oxygenation. Oxygen administration is done after positing the client on to the lateral position.

A. Insert a urinary catheter. B. Massage the fundus. C. Have the client urinate. D. Administer an analgesic

Correct Answer is C

Explanation

A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client

urinate voluntarily. Administering an analgesic is not indicated based on the information provided.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

Correct Answer is C

Explanation

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