A nurse is caring for a newborn following delivery. Which of the following actions should the nurse take first?
Obtain the newborn's weight.
Administer IM vitamin K.
Apply identification bands to the newborn.
Apply prophylactic eye ointment.
The Correct Answer is C
Identification bands are an important safety measure to ensure that the newborn is properly identified and matched with the correct mother. Applying identification bands to the newborn and mother is a standard practice in all healthcare settings and is typically done immediately following delivery.
While obtaining the newborn's weight, administering IM vitamin K, and applying prophylactic eye ointment are also important interventions for a newborn, they should be done after the identification bands are applied. The order of priority for these interventions may vary depending on the healthcare facility's policies and procedures, but ensuring proper identification of the newborn is always the first step to ensure patient safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
The nurse should plan to immunize the client with the following vaccines: Inactivated influenza: The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women receive the influenza vaccine during any trimester of pregnancy, as pregnant women are at an increased risk of severe illness from the flu.
Diphtheria-acellular pertussis: The CDC recommends that pregnant women receive the Tdap vaccine (which includes protection against tetanus, diphtheria, and acellular pertussis) during each pregnancy, ideally between 27 and 36 weeks of gestation. This is to protect both the mother and the newborn from pertussis (whooping cough).
The following vaccines are not recommended:
Measles, mumps and rubella vaccine should not be given during pregnancy.
The HPV vaccine is not routinely recommended during pregnancy, and if the client becomes pregnant while receiving the HPV vaccine series, vaccination should be delayed until after the pregnancy.
The varicella vaccine (which protects against chickenpox) is not recommended during pregnancy, and if the client is not immune to chickenpox, the vaccine should be given after the pregnancy is over.
Correct Answer is D
Explanation
Magnesium sulfate is a medication commonly used to treat preeclampsia, a pregnancy-related condition characterized by high blood pressure and damage to other organ systems, such as the kidneys. However, magnesium sulfate can also cause adverse reactions, and the nurse should be aware of these reactions.
The nurse should recognize that a urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate, as magnesium sulfate can cause decreased urine output, which can lead to dehydration and electrolyte imbalances. The nurse should promptly report this finding to the provider, as it may require immediate intervention.
Option A is incorrect because hypertension is a symptom of preeclampsia, not an adverse reaction to magnesium sulfate.
Option B is also incorrect because hyperglycemia is not an adverse reaction to magnesium sulfate.
Option C is also incorrect because a respiratory rate of 16/min is within the normal range.
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