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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.

A. The client is taking an antidepressant. B. The client has a history of a seizure disorder. C. The client takes aspirin daily. D. The client has a history of rheumatoid arthritis

Correct Answer is C

Explanation

- A: Garlic supplements are not contraindicated for clients taking antidepressants. While garlic is known to have a variety of health benefits, there is no well-documented interaction between garlic supplements and antidepressants that would contraindicate their concurrent use.
- B: There is no direct contraindication for the use of garlic supplements in clients with a history of seizure disorders. Garlic supplements do not have a seizure threshold-lowering effect, which is a common concern with some medications and conditions that may exacerbate seizure disorders.
- C: Garlic supplements may increase the risk of bleeding, especially when taken with other substances that have anticoagulant properties, such as aspirin. This is due to garlic's potential effect on platelet aggregation and the blood clotting process, making it a contraindication for clients who take aspirin daily.
- D: Garlic supplements do not have a contraindication for clients with a history of rheumatoid arthritis. In fact, some studies suggest that garlic may have anti-inflammatory properties, which could be beneficial for individuals with inflammatory conditions like rheumatoid arthritis.

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A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

Correct Answer is C

Explanation

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