A nurse on the labor and delivery unit is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?
Assign an Apgar score to the newborn.
Dry the newborn.
Weigh the newborn.
Place an identification bracelet on the newborn.
The Correct Answer is B
Choice A rationale:
Assigning an Apgar score is important, but drying the newborn and promoting warmth are immediate priorities.
Choice B rationale:
Drying the newborn and providing warmth help prevent heat loss and maintain the newborn's body temperature, which is essential for their well-being.
Choice C rationale:
Weighing the newborn is important, but maintaining their body temperature takes precedence immediately after birth.
Choice D rationale:
Placing an identification bracelet on the newborn is important for proper identification, but ensuring the newborn's immediate well-being and comfort is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
Correct Answer is C
Explanation
Choice A rationale:
Administering all the missed immunizations in one injection is not recommended and can lead to increased discomfort and potential adverse reactions.
Choice B rationale:
Starting the immunization series over is unnecessary and can delay the child's protection against vaccine-preventable diseases.
Choice C rationale:
The most appropriate action is to administer the immunizations the child missed at the earliest opportunity to catch up on the schedule.
Choice D rationale:
Waiting until 12 months of age is not necessary if the child has already missed scheduled immunizations. The catch-up schedule should be followed based on the child's current age.
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