A nurse is caring for a newborn immediately following delivery. Which of the following actions should be the nurse's priority in the resuscitation of this neonate?
Administer phytonadione IM and erythromycin in both eyes
Document the Apgar score.
Apply identification bands.
Dry and stimulate the newborn: position and open the airway, clear secretions if necessary
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice A: Go to break is not an appropriate action, as it can delay the necessary interventions and compromise the fetal well-beinG. The nurse should stay with the mother and monitor the fetal heart rate and the uterine activity continuously.
Choice B: Apply 100% non-rebreather mask is an appropriate action, as it can increase the maternal oxygenation and improve the fetal oxygen delivery. The nurse should place a mask with a reservoir bag over the mother's nose and mouth and adjust the flow rate to 10 to 15 L/min.
Choice C: Give an IV fluid bolus is an appropriate action, as it can increase the maternal blood volume and improve the uterine perfusion. The nurse should administer 500 to 1000 mL of isotonic crystalloid solution rapidly through a large-bore IV catheter.
Choice D: Reposition the mother is an appropriate action, as it can relieve the uterine or cord compression and improve the fetal circulation. The nurse should turn the mother to the left or right lateral position or place her in a knee-chest position.
Choice E: Increase the oxytocin drip is not an appropriate action, as it can increase the uterine contractions and reduce the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
Choice F: Decrease or stop the oxytocin is an appropriate action, as it can decrease the uterine contractions and increase the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
Correct Answer is C
Explanation
Choice A reason: This is not the correct response because a cephalhematoma is a collection of blood under the periosteum of the skull that does not cross the suture linE. It usually takes several weeks to months to resolvE.
Choice B reason: This is not the correct response because erythema toxicum is a benign rash that appears as red macules or papules with white or yellow centers. It does not cause swelling on the head and can occur anywhere on the body.
Choice C reason: This is the correct response because a caput succedaneum is a collection of fluid under the scalp that crosses the suture linE. It is caused by pressure from the vacuum extractor or the birth canal. It usually resolves within a few days.
Choice D reason: This is not the correct response because a Mongolian spot is a bluish-gray or brown patch of pigmentation that is usually found on the lower back or buttocks. It does not cause swelling on the head and is not related to the mode of delivery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.