A nurse is caring for a newborn 1 hr following birth.

The newborn was delivered via emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate. The Apgar score was 5 at 1 min.

Positive pressure ventilation was given for 1 min followed by free flow oxygen.
What finding should the nurse report to the provider?

Hemoglobin

Hematocrit

Serum glucose

Respiratory assessment

Temperature

Answer and Explanation

The Correct Answer is D

Choice A rationale

Hemoglobin is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.

Choice B rationale

Hematocrit is a measure of the proportion of red blood cells in the blood. While it is an important parameter to monitor in newborns, it is not one of the immediate findings that the nurse should report to the provider in this context.

Choice C rationale

Serum glucose is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.

Choice D rationale

A respiratory assessment is crucial for a newborn, especially one that has undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non- reassuring fetal heart rate. The newborn’s Apgar score was 5 at 1 min, which indicates significant distress, and positive pressure ventilation was given for 1 min followed by free flow oxygen. These factors make respiratory assessment a priority and one of the immediate findings that the nurse should report to the provider.

Choice E rationale

Temperature is an important parameter to monitor in newborns, especially those who have undergone a stressful birth process like an emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. However, it is not one of the immediate findings that the nurse should report to the provider in this context.

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Correct Answer is D

Explanation

Choice A rationale

Administering Vitamin K is an important step in newborn care as it helps with blood clotting and prevents a rare but serious bleeding disorder called Vitamin K Deficiency Bleeding.

However, it is not the immediate priority after ensuring a patent airway.

Choice B rationale

Administering eye prophylaxis, typically in the form of antibiotic ointment, is a standard procedure in newborn care to prevent neonatal conjunctivitis. However, this is not the immediate priority after ensuring a patent airway.

Choice C rationale

Placing an identification bracelet on the newborn is crucial for ensuring the baby’s safety and preventing mix-ups. However, this is not the immediate priority after ensuring a patent airway.

Choice D rationale

Drying the skin of the newborn is the priority action after ensuring a patent airway. This is because newborns are wet with amniotic fluid at birth, and they can lose heat quickly through evaporation if not dried immediately. This can lead to hypothermia, which can be dangerous for the newborn.

A. Turn the newborn on his side. B. Suction the mouth with a bulb syringe. C. Suction the nose with a bulb syringe. D. Use a suction catheter with low negative pressure.

Correct Answer is B

Explanation

Choice A rationale

Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.

Choice B rationale

Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.

Choice C rationale

Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.

Choice D rationale

Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Choice E rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse’s priority action?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client who has just delivered a newborn. The nurse notices secretions bubbling out of the newborn’s nose and mouth. Which of the following actions should the nurse prioritize?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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