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. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.
B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.
C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.
D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.
Correct Answer is ["A","B","D","E"]
Explanation
A. Echolalia, or repeating the words of others, can be a manifestation of schizophrenia.
B. Word salad, or a jumble of incoherent words and phrases, can occur in schizophrenia.
C. Expressing interest in ADLs is not typically associated with schizophrenia and may indicate a different mental health state.
D. A blunt affect, or reduced emotional expression, is a common symptom of schizophrenia.
E. Delusions, or fixed false beliefs, are a hallmark symptom of schizophrenia.
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