A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Confirm the newborn's Apgar score

Verify the newborn's identification.

Administer vitamin K to the newborn.

Determine obstetrical risk factors.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Confirming the newborn's Apgar score is important for assessing the newborn's overall condition, but it may not be the first priority.

Choice B Reason:

Verifying the newborn's identification is appropriate. Ensuring accurate identification is a crucial step in newborn care to prevent errors and ensure that interventions are carried out on the correct infant.

Choice C Reason:

Administering vitamin K is a standard practice but can wait until after the newborn's identification is confirmed.

Choice D Reason:

Determining obstetrical risk factors is part of the overall assessment but is not the immediate priority in this situation.

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Correct Answer is B

Explanation

A. Fetal lie being longitudinal is a normal and common fetal lie. It refers to the long axis of the fetus being parallel to the long axis of the mother.

B. Fetal position being persistent occiput posterior is a potential contributing cause.

Occiput posterior position (OP) can result in a more challenging and prolonged labor. This position, where the back of the baby's head is facing the mother's spine, is associated with increased back pain during labor.

C. Fetal attitude in general flexion is a favorable presentation for labor. Flexion allows for a smaller presenting diameter of the fetal head, facilitating descent through the birth canal.

D. Maternal pelvis being gynecoid is a favorable pelvic type for childbirth. The gynecoid pelvis is typically associated with easier labor and delivery.

A. Contractions that last 45 seconds each with a 3 min rest between contractions B. Contractions that last for 60 seconds each with a 3-min rest between contractions C. Contractions that last for 60 seconds each with a 4-min rest between contractions D. A contraction that lasts 4 min followed by a period of relaxation

Correct Answer is B

Explanation

A. Contractions that last 45 seconds each with a 3-minute rest between contractions are less common. Typically, contractions last around 60 seconds during active labor.

B. Contractions that last for 60 seconds each with a 3-min rest between contractions is the expected pattern.

During active labor, contractions are commonly around 60 seconds in duration, and they occur approximately every 4-5 minutes.

C. Contractions that last for 60 seconds each with a 4-min rest between contractions are not consistent with the usual pattern of contractions in active labor. A 4-minute rest between contractions would be an extended interval.

D. A contraction that lasts for 4 minutes followed by a period of relaxation is not typical and may indicate a problem. Normal contractions usually last around 60 seconds or less.

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A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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