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?
Administer Vitamin K
Administer eye prophylaxis
Place an identification bracelet
Dry the skin
The Correct Answer is D
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.
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Correct Answer is D
Explanation
Choice A rationale: An awake, alert, and crying newborn is a common observation and does not specifically indicate Neonatal Abstinence Syndrome (NAS). Newborns have varying sleep-wake cycles, and it’s normal for them to have periods of being awake and alert. Crying is also a normal behavior for newborns as it’s their primary means of communication. It could indicate a variety of needs such as hunger, the need for a diaper change, or just the need for comfort and contact. Therefore, while an excessively crying baby could potentially be a sign of discomfort or distress, it is
not specifically indicative of NAS.
Choice B rationale: The presence of acrocyanosis, which is the bluish color of the hands and feet, is a normal finding in the first 24 to 48 hours of life due to immature circulation. It’s not specifically associated with NAS. NAS is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Acrocyanosis is generally not a symptom of NAS.
Choice C rationale: A respiratory rate of 70/min is higher than the normal range (30-60/min) for a newborn and could indicate respiratory distress. However, it’s not specifically indicative of NAS. There are many potential causes of tachypnea (increased respiratory rate) in a newborn, including transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, meconium aspiration syndrome (MAS), and more. While infants with NAS mayexperience symptoms such as stuffy nose, sneezing, and rapid breathing, a high respiratory rate alone is not specifically indicative of NAS.
Choice D rationale: Jitteriness in the hands of a newborn can be a sign of Neonatal Abstinence Syndrome (NAS). NAS is a drug withdrawal syndrome in newborns that occurs primarily among opioid-exposed infants shortly after birth, often manifested by central nervous system irritability, autonomic overreactivity, and gastrointestinal tract dysfunction. Jitteriness or tremors, especially when disturbed, along with other signs such as high-pitched crying, poor feeding, and
loose stools, are more indicative of NAS.
Correct Answer is A
Explanation
Choice A rationale
Turning the client onto her side is the first action the nurse should take when late decelerations are noted on the fetal monitor. Late decelerations can indicate uteroplacental insufficiency, and turning the client onto her side can improve placental blood flow and oxygen delivery to the fetus.
Choice B rationale
Increasing the client’s IV fluid infusion rate can help increase maternal blood volume and improve placental perfusion. However, it is not the first action to take when late decelerations are noted.
Choice C rationale
Palpating the client’s uterus can provide information about the strength, duration, and frequency of contractions, but it is not the first action to take when late decelerations are noted.
Choice D rationale
Administering oxygen to the client can increase the amount of available oxygen for fetal oxygenation. However, it is not the first action to take when late decelerations are noted.
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