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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should withhold the terbutaline and report to the provider if the client's blood pressure is 88/58 mm Hg. Terbutaline can cause hypotension, and a blood pressure reading in this range indicates the client is already experiencing low blood pressure. The provider may need to adjust the medication dosage or consider an alternative medication.
The other findings are within normal ranges and would not require withholding the medication or reporting to the provider:
Fasting blood glucose of 75 mg/dL is within the normal range.
FHR of 120/min is within the normal fetal heart rate range.
Urinary output of 40 ml/hr is within normal range, although it should be monitored for any signs of decreased urine output as this could indicate dehydration.
Correct Answer is B
Explanation
Retained placental fragments is a risk factor for postpartum hemorrhage. When placental fragments remain in the uterus, they prevent the uterus from contracting down and can cause significant bleeding. Pregnancy-induced hypertension, oligohydramnios, and meconium-stained fluid are not considered risk factors for postpartum hemorrhage.
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