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 A
Explanation
Choice A reason:
Smoking is the most significant risk factor for clubfoot, according to several studies that have found a strong association between maternal smoking during pregnancy and the occurrence of clubfoot in the offspring. Smoking may affect the development of the muscles and tendons in the fetus, leading to abnormal positioning of the foot.
Choice B reason:
Trauma during pregnancy is not a significant risk factor for clubfoot, as there is no evidence that physical injury to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Choice C reason:
Hypertension is not a significant risk factor for clubfoot, as there is no evidence that high blood pressure in the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Choice D reason:
Decreased circulation is not a significant risk factor for clubfoot, as there is no evidence that poor blood flow to the mother or the fetus can cause this deformity. Clubfoot is a congenital condition that is present at birth and usually detected by prenatal ultrasound.
Correct Answer is A
Explanation
Choice A reason:
This is a normal WBC for a newborn. According to MedlinePlus, the normal amount of white blood cells (WBCs) found in the bloodstream of a newborn infant is between 4,500 and 10,000 per microliter of blood. The reference ranges for WBC count established by Mayo Medical Laboratories for infants from birth to 2 years are as follows:.
• Birth: 9.0 to 30.0 x 10 9 /L.
• 1 to 7 days: 9.4 to 34.0 x 10 9 /L.
• 8 to 14 days: 5.0 to 21.0 x 10 9 /L.
• 15 days to 1 month: 5.0 to 20.0 x 10 9 /L.
• 2 to 5 months: 5.0 to 15.0 x 10 9 /L. Therefore, a newborn's WBC of 15,000 is within the normal range and does not indicate any problem.
Choice B reason:
You must call the doctor. This is not a correct answer because there is no need to call the doctor for a normal WBC in a newborn. Calling the doctor unnecessarily may cause anxiety and a waste of time and resources.
Choice C reason:
This indicates a severe infection. This is not a correct answer because a WBC of 15,000 does not necessarily indicate a severe infection in a newborn. A high WBC, also called leukocytosis, may be related to infection, but it can also be caused by other factors such as stress, inflammation, trauma, medication, or blood disorders. Moreover, the type and severity of infection can be better assessed by looking at the differential count of the different types of white blood cells (neutrophils, eosinophils, basophils, monocytes, and lymphocytes) and other signs and symptoms.
Choice D reason:
This is a lab error. This is not a correct answer because a WBC of 15,000 is not likely to be a lab error in a newborn. Lab errors can occur due to improper collection, handling, or analysis of blood samples, but they are rare and usually detected by quality control measures. A WBC of 15,000 is within the normal range for a newborn and does not require repeating the test unless there is a strong suspicion of an error or an inconsistency with other results or clinical findings.
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