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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Hypertonia is not a characteristic of a preterm infant, but rather of a post-term infant. Hypertonia means increased muscle tone or stiffness, which is more common in infants who are overdue. Preterm infants have poor muscle tone and less subcutaneous fat.
Choice B reason:
Long toenails are also not a characteristic of a preterm infant but of a post-term infant. Long toenails indicate that the infant has grown beyond the expected gestational age. Preterm infants have short and brittle nails.
Choice C reason:
Lanugo is a characteristic of a preterm infant. Lanugo is fine, downy hair that covers the body of the fetus. It usually disappears by the 36th week of gestation, but preterm infants may still have it at birth.
Choice D reason:
Dry skin is not a characteristic of a preterm infant but of a post-term infant. Dry skin indicates that the infant has lost moisture and subcutaneous fat due to prolonged exposure to the amniotic fluid. Preterm infants have thin and transparent skin that may be covered by vernix caseosa, a white, cheesy substance that protects the skin from the amniotic fluid.
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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