A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority?
Dry the newborn.
Administer phytonadione IM.
Document the Apgar score.
Apply identification bands.
The Correct Answer is A
Choice A reason:
Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.
Choice B reason:
Administering phytonadione IM is not the nurse's priority because it is not an immediate life-saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.
Choice C reason:
Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.
Choice D reason:
Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F","G"]
Explanation
Choice A:
Temperature is not a finding that the nurse should report to the provider. The normal range for temperature in newborns is 36.5 to 37 degrees Celsius axillary. The question does not provide the temperature of the newborn, but it does not indicate any signs of hypothermia or hyperthermia.
Choice B:
Respiratory findings are findings that the nurse should report to the provider. The newborn has mild grunting, nasal flaring, and intermittent retractions, which are signs of respiratory distress. These could indicate a problem with lung development, infection, or congenital heart disease.
Choice C:
Serum glucose is a finding that the nurse should report to the provider. The normal range for blood glucose in newborns is above 40 mg/dL. The question does not provide the serum glucose level of the newborn, but it could be low due to factors such as prematurity, maternal diabetes, or sepsis.
Choice D:
Hematocrit is a finding that the nurse should report to the provider. The normal range for hematocrit in newborns is 42% to 65%. The question does not provide the hematocrit level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice E:
White blood cell count is not a finding that the nurse should report to the provider. The normal range for white blood cell count in newborns is 9,000 to 30,000/mm3. The question does not provide the white blood cell count of the newborn, but it does not indicate any signs of infection or inflammation.
Choice F:
Hemoglobin is a finding that the nurse should report to the provider. The normal range for hemoglobin in newborns is 14 to 24 g/dL. The question does not provide the hemoglobin level of the newborn, but it could be high due to polycythemia or low due to anemia or hemorrhage.
Choice G:
Heart rate is a finding that the nurse should report to the provider. The normal range for heart rate in newborns is 85 to 190 beats per minute when awake. The question does not provide the heart rate of the newborn, but it could be high due to stress, pain, fever, or hypoxia, or low due to bradycardia or cardiac arrest.
Correct Answer is B
Explanation
Choice A reason:
Swimming is one of the best and safest exercises for pregnant women. It exercises your large muscle groups, provides cardiovascular benefits, reduces swelling, and allows you to feel weightless. Swimming is also a low-impact exercise that does not put too much stress on your joints and muscles. Therefore, this statement does not indicate a need for additional teaching.
Choice B reason:
Racquetball is not an appropriate exercise during pregnancy. It is a high-impact sport that involves sudden changes of direction, quick movements, and the risk of falling or getting hit by the ball or the racquet. These factors can increase the chance of injury, bleeding, or premature labor. Therefore, this statement indicates a need for additional teaching.
Choice C reason:
Cycling on a stationary bike is a safe exercise during pregnancy. It provides moderate aerobic conditioning and relieves stress and tension in your joints and muscles. Cycling on a stationary bike also reduces the risk of falling or losing balance compared to cycling on a regular bike. Therefore, this statement does not indicate a need for additional teaching.
Choice D reason:
Yoga is a beneficial exercise during pregnancy. It can help you relax, improve your flexibility, strengthen your muscles, and prepare your body for labor and delivery. Yoga can also help you cope with symptoms of depression and anxiety during pregnancy. However, you should avoid hot yoga or poses that involve lying flat on your back, twisting your abdomen, or compressing your belly. Therefore, this statement does not indicate a need for additional teaching.
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