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 D

Explanation

At 22 weeks of gestation, the fundal height is typically around the level of the umbilicus or slightly above it.

A. The largest fetal diameter has passed through the pelvic outlet. B. The fetal head is in the left occiput posterior position. C. The posterior fontanel is palpable. D. The lowermost portion of the fetus is at the level of the ischial spines.

Correct Answer is D

Explanation

Rationale

Station refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis, which serve as a reference point during labor.

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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 preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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