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 B

Explanation

A. Moderate bright red lochial flow on postpartum day 14 may indicate excessive bleeding and is not indicative of normal involution.
B. A fundus below the symphysis and nonpalpable suggests a well-contracted uterus, which is indicative of normal involution.
C. An episiotomy that is slightly red and puffy on day 14 may indicate ongoing healing, but it is not a direct measure of uterine involution.
D. Breasts that are firm and tender on postpartum day 14 may indicate engorgement, but they are not directly related to uterine involution.

A. Encourage the client to perform Kegel exercises. B. Encourage the client to move to the left lateral position. C. Ask the client to rate her pain. D. Encourage the client to empty bladder by voiding

Correct Answer is D

Explanation

A. Kegel exercises are not indicated for addressing a boggy uterus; emptying the bladder is a more appropriate intervention.
B. Moving to the left lateral position may help, but the primary concern is a full bladder contributing to uterine displacement.
C. Pain assessment is important but does not directly address the issue of a boggy uterus and displacement.
D. Encouraging the client to empty the bladder by voiding is essential, as a full bladder can displace the uterus and contribute to uterine atony.

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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

Which documentation on a woman's chart on postpartum day 14 indicates a normal involution process?

Correct Answer is B

Explanation

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time?

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security?

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?