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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Correct Answer is ["B","D","E"]

Explanation

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours.
B. Padding bony prominences helps prevent skin breakdown and pressure injuries.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in an emergency.
D. Removing the restraints every 2 hours allows for circulatory assessment, skin care, and range of motion exercises.
E. The provider's prescription should specify the type of restraint to ensure proper and appropriate use.

A. Encourage client fluid intake of 2,500 mL daily. B. Moisturize dry skin areas on the client every other day. C. Place a dehumidifier in the client's room. D. Apply a donut ring pillow under the client's sacral area.

Correct Answer is A

Explanation

A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.

B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.

C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.

D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.

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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 manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is A

Explanation

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