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 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 C
Explanation
Choice A reason:
Heat facilitates the drainage of mucus for a premature newborn. This is incorrect because heat does not affect mucus drainage. Mucus drainage is more related to suctioning and hydration.
Choice B reason:
The newborn has a small body surface for his weight. This is incorrect because a small body surface area for weight would indicate a large newborn, not a premature one. A large newborn would have less risk of heat loss than a small one.
Choice C reason:
The newborn's temperature control mechanism is immature. This is correct because premature newborns have immature thermoregulation and are prone to hypothermia. Placing the newborn in an incubator helps maintain a stable temperature and prevent further complications.
Choice D reason:
Heat increases the flow of oxygen to the newborn's extremities. This is incorrect because heat does not directly affect oxygen delivery. Oxygen delivery is more related to ventilation, perfusion, and hemoglobin levels. The question is about a premature newborn who has signs of respiratory distress, such as nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. These signs indicate that the newborn is having difficulty breathing and may have a condition such as respiratory distress syndrome, transient tachypnea of the newborn, or meconium aspiration syndrome. The nurse should place the newborn in an incubator to provide warmth and prevent heat loss, which can worsen respiratory distress. The nurse should also monitor the newborn's vital signs, oxygen saturation, blood gases, chest x-ray, and neonatal abstinence scoring system if indicated. The nurse should be prepared to administer oxygen, surfactant, or mechanical ventilation as ordered.
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