A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?
Instill erythromycin ophthalmic ointment in the newborn's eyes.
Weigh the newborn.
Place identification bracelets on the newborn.
Dry the newborn.
The Correct Answer is D
A. Instilling erythromycin ophthalmic ointment in the newborn's eyes is important to prevent neonatal conjunctivitis, but drying the newborn takes precedence to prevent heat loss and stimulate breathing immediately after birth.
B. Weighing the newborn and placing identification bracelets can be done after drying the newborn.
C. Placing identification bracelets on the newborn is important for identification purposes but does not take precedence over drying the newborn to prevent heat loss and stimulate breathing.
D. Dry the newborn: Drying the newborn is the priority immediately after birth to prevent heat
loss and stimulate breathing. The newborn is wet from amniotic fluid and may be cold due to the temperature difference between the intrauterine and extrauterine environment. Drying the newborn with a warm, soft towel helps to prevent hypothermia and promotes the initiation of breathing, which is essential for oxygenation and lung expansion. This action supports the
newborn's transition to extrauterine life and sets the stage for subsequent assessments and interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Taking pancrelipase on an empty stomach may not provide optimal effectiveness as there would be no food in the stomach to mix with the enzymes for proper digestion.
B. Taking pancrelipase 1 hour before meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.
C. Taking pancrelipase 1 hour after meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.
D. Taking pancrelipase with meals is the correct instruction. Pancrelipase supplements the digestive enzymes that are deficient in individuals with cystic fibrosis, helping them digest food properly. Taking it with meals ensures that the enzymes are present when food enters the stomach, optimizing digestion and nutrient absorption.
Correct Answer is D
Explanation
A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.
B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.
C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.
D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.
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