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 C

Explanation

A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.

B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.

C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.

D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.

A. Blood glucose level of 120 mg/dL B. Serum sodium 138 mEq/L C. Oral temperature of 37.6°C (99.7°F) D. Weight increase of 2 kg (4.4 lb) in the past 24 hr

Correct Answer is D

Explanation

A. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.

B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.

C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.

D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.

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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?

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