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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A........ Therefore, it poses the greatest risk to a newborn who is 30
minutes old.
Choice B rationale
Birth weight can influence a newborn’s health, with low birth weight associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Choice C rationale
Gestational age can influence a newborn’s health, with preterm birth associated with various health problems. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Choice D rationale
Fetal Undergrowth Anomaly (FUA) refers to a condition where a fetus does not grow at the expected rate during pregnancy. It can lead to various health problems for the newborn. However, it is less immediately life-threatening compared to meconium aspiration syndrome.
Correct Answer is C
Explanation
Choice A rationale
Monitoring axillary temperature is important for all newborns to prevent hypothermia. However, it is not the priority intervention for a newborn who is small for gestational age (SGA). These newborns are at a higher risk for hypoglycemia due to decreased stores of glycogen and a lower rate of gluconeogenesis.
Choice B rationale
Monitoring weight is important for all infants, and ongoing monitoring is important for infants who are SGA. However, it is not the priority intervention for this client at this time.
Choice C rationale
This is the correct answer. Newborns who are SGA are at a higher risk for hypoglycemia. Therefore, monitoring of blood glucose levels is a priority intervention.
Choice D rationale
Providing age-appropriate stimulation is important for all newborns. However, it is not the priority intervention for a newborn who is SGA2.
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