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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Position the client with one hip elevated.
A. Having the client void is a good practice, but it is not the priority action in this situation. The client's vital signs suggest a potential issue with uteroplacental perfusion, and repositioning the client should be the priority.
B. Positioning the client with one hip elevated is the priority action.
The vital signs, specifically the low blood pressure, may be indicative of aortocaval compression (supine hypotension). Elevating one hip helps alleviate this compression, improving blood flow and potentially addressing the decreased blood pressure.
C. Asking the client if she needs pain medication is important, but repositioning the client takes precedence due to the potential issue with blood pressure and uteroplacental perfusion.
D. Notifying the provider is important, but repositioning the client to improve blood flow should be done first. The provider may be notified afterward based on the client's response and ongoing assessment.
Correct Answer is B
Explanation
The correct answer is B. Just above the symphysis pubis.
A. Just above the umbilicus: At the end of the first trimester, the uterus is still within the pelvic cavity, and fetal heart tones are typically not detectable above the umbilicus at this stage.
B. Just above the symphysis pubis: This is the correct placement for assessing fetal heart tones during the first trimester. The fetal heart is usually located low in the pelvis during early pregnancy, making it most easily heard just above the pubic bone.
C. The right lower quadrant: Fetal heart tones are typically assessed in the midline of the abdomen, and focusing on the lower quadrants may not be the optimal location, especially in the first trimester.
D. The left lower quadrant: Similar to the right lower quadrant, focusing on the lower quadrants may not be the most appropriate location for assessing fetal heart tones during the first trimester.
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