A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Place an identification bracelet.

Dry the skin.

Administer vitamin K.

Administer eye prophylaxis.

Answer and Explanation

The Correct Answer is B

A.   Placing an identification bracelet is important but not the immediate priority after ensuring a patent airway.
B.   Drying the skin is a priority to prevent heat loss and promote thermoregulation in the newborn.
C. Administering vitamin K is important but can be done after drying the skin.
D.   Administering eye prophylaxis is important but can be done after drying the skin.

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Correct Answer is A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

A. The nurse should immediately notify the pediatrician for this emergency situation B. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth C. The neonate must have aspirated surfactant D. If this baby was born vaginally, then a pneumothorax could be indicated

Correct Answer is B

Explanation

A. Moist lung sounds in this context are not indicative of an emergency situation requiring immediate notification of the pediatrician.
B. Moist lung sounds in a baby born by cesarean section are common and may be due to retained lung fluid, often resolving within the first 24 hours after birth. This is because the baby does not experience the same compression of the chest during delivery as a baby born vaginally, which helps to expel some of the fluid from the lungs.
C. Aspiration of surfactant is not a common or likely occurrence.
D. Moist lung sounds are not typically indicative of a pneumothorax, especially in the absence of other signs and symptoms.

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A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Correct Answer is A

Explanation

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

Correct Answer is B

Explanation

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