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 D
Explanation
Choice A: Increasing IV fluid rate is a secondary action, as it helps restore the blood volume and improve the blood pressure and the fetal perfusion. The nurse should perform this action after taking the first action.
Choice B: Elevating the legs is a tertiary action, as it helps increase the venous return and the cardiac output and improve the blood pressure and the fetal perfusion. The nurse should perform this action after taking the first and second actions.
Choice C: Notifying the provider is a quaternary action, as it helps communicate the situation and obtain further orders and interventions. The nurse should perform this action after taking the first, second, and third actions.
Choice D: Placing the client in a lateral position to relieve pressure on the inferior vena cava is the first and most important action, as it helps prevent or correct the hypotension and the fetal bradycardia caused by the epidural anesthesia block. The epidural anesthesia block can block the sympathetic nerve fibers and cause vasodilation and pooling of blood in the lower extremities, which can reduce the blood pressure and the placental perfusion. The pressure of the gravid uterus on the inferior vena cava can also reduce the venous return and the cardiac output, which can worsen the hypotension and the fetal bradycardiA. By placing the client in a lateral position, the nurse can reduce the pressure on the inferior vena cava and improve the blood flow and the oxygen delivery to the fetus.
Correct Answer is A
Explanation
Choice A reason: This is the correct action because a full bladder can cause the uterus to be displaced and prevent it from contracting properly, leading to uterine atony and excessive bleedinG. Asking the client to empty her bladder can help the fundus to return to the midline and reduce the lochiA.
Choice B reason: This is not the correct action because the client's temperature is within the normal range for the first 24 hours postpartum. A slight elevation in temperature can be due to dehydration, exertion, or milk production. The nurse should monitor the client's temperature and encourage fluid intake, but it is not a priority action.
Choice C reason: This is not the correct action because increasing IV fluids can cause fluid overload and worsen the bleedinG. The nurse should assess the client's fluid status and adjust the IV rate accordingly, but it is not a priority action.
Choice D reason: This is not the correct action because encouraging the client to nurse more frequently can stimulate oxytocin release and cause more uterine contractions and bleedinG. The nurse should support the client's breastfeeding practices, but it is not a priority action.
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