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 A
Explanation
The correct answer is A. Cervical dilation.
A. Cervical dilation is a definitive sign of labor.
Cervical dilation is the opening of the cervix, and it is a key indicator of the active phase of labor. Measurement of cervical dilation is an essential component of assessing the progress of labor.
B. Brownish vaginal discharge may indicate various things, including the presence of old blood or mucus. While it could be a sign of impending labor, it is not a definitive confirmation of active labor.
C. Amniotic fluid in the vaginal vault could suggest rupture of membranes, but it alone does not confirm the active phase of labor.
D. Pain above the umbilicus is not a specific or conclusive sign of labor. Labor pain typically originates in the lower abdomen and pelvis.
Correct Answer is C
Explanation
Choice A Reason:
Hemoglobin (Hgb) of 20 g/dL is elevated, but this can be a normal finding in a newborn and does not necessarily require immediate intervention.
Choice B Reason:
Total bilirubin of 5 mg/dL is within the normal range for a 24-hour-old newborn.
Choice C Reason:
Blood glucose 30 mg/dL. A blood glucose level of 30 mg/dL is significantly lower than the normal range for a newborn. Hypoglycemia in a newborn can lead to neurologic complications, so it is important to report this result promptly for further evaluation and intervention.
Choice D Reason:
White blood cell (WBC) count of 20,000/mm³ is within the expected range for a newborn and is not a cause for immediate concern. Newborns often have higher WBC counts shortly after birth.
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