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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I will receive this medication if my baby is Rh-negative." This statement does not record understanding of the teaching. The purpose of Rho(D) immune globulin is to prevent sensitization of an Rh-negative mother to Rh-positive fetal blood. If the baby is Rh-negative, there is no need for Rho(D) immune globulin.
Choice B Reason:
"I will receive this medication when I am in labor." This statement does not record understanding of the teaching. Rho(D) immune globulin is typically given around 28 weeks of pregnancy and possibly after events that could lead to mixing of maternal and fetal blood, not specifically during labor.
Choice C Reason:
"I will need a second dose of this medication when my baby is 6 weeks old." This statement does not record understanding of the teaching. The administration of Rho(D) immune globulin is generally based on events during pregnancy and delivery, and a second dose is not typically given postpartum unless the baby is Rh-positive.
Choice D Reason:
"I will need this medication if I have an amniocentesis." This statement records understanding of the teaching. Rho(D) immune globulin is given to Rh-negative women during pregnancy and certain other situations to prevent the development of Rh incompatibility with a Rh-positive baby. If the mother undergoes procedures such as amniocentesis or experiences events that could lead to mixing of maternal and fetal blood, Rho(D) immune globulin is administered.
Correct Answer is C
Explanation
The correct answer is C. Continuous contraction lasting 2 min.
A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.
B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.
C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.
A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.
D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.
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