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 B

Explanation

The symptoms describe indicate the presence of DVT which is a serious complication associated with childbirth. In addition to advising the client to see her provider immediately, the nurse should suggest interventions such as limb elevate to promote venous return and minimize discomfort.

A. Massaging the affected area can dislodge the blood clot and lead to a pulmonary embolism.

C. Cold compresses may help reduce pain and inflammation, but they do not address the underlying issue of a potential DVT.
D. Flexing the knee while resting can help improve blood flow in the affected leg and prevent stagnation but does not address the issue.

A. Less than 2.5 cm of rubra lochia on perineal pad B. Fundus palpable to right of midline C. Client report of frequent uterine contractions D. Client report of increased thirst

Correct Answer is B

Explanation

One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.

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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

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Explanation

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Correct Answer is B

Explanation

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