Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?

Give blow-by oxygen via cannula.

Start IV infusion in a scalp vein.

Assist neonatologist with intubation.

Provide positive pressure ventilation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.

Choice B rationale

Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.

Choice C rationale

Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.

Choice D rationale

Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.

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Correct Answer is B

Explanation

Choice A rationale

The client has a hemoglobin level of 12 g/dL and a hematocrit of 34%, which are within normal ranges for a postpartum woman. A blood transfusion is typically indicated for severe anemia or significant blood loss, neither of which is suggested by these lab results. Therefore, a blood transfusion is not warranted in this case.

Choice B rationale

Rubella vaccination is indicated for a client who is non-immune to rubella, as indicated by the laboratory results. Rubella vaccination is important to protect the client from contracting rubella in future pregnancies, which can cause serious congenital defects. Since the client is not currently pregnant and not immune, vaccination can be safely administered postpartum to prevent future rubella infections.

Choice C rationale

Penicillin G potassium is an antibiotic that might be used for a client who is group B Streptococcus positive to prevent neonatal infection during delivery. However, this client is group B Streptococcus negative, so there is no indication for this antibiotic. There is no need to administer Penicillin G potassium in this scenario.

Choice D rationale

Hepatitis B immunoglobulin is used for newborns of mothers who are hepatitis B surface antigen positive to prevent perinatal transmission of the virus. Since the client's lab results indicate she is hepatitis B surface antigen negative, there is no need for Hepatitis B immunoglobulin. The client and her newborn are not at risk of hepatitis B transmission, so this intervention is not required. .

A. Return of the uterus to prepregnancy size. B. Stimulation of uterine contractions. C. Activation of the let-down reflex. D. Expulsion of the placenta.

Correct Answer is B

Explanation

Choice A rationale

Oxytocin is not involved in returning the uterus to its prepregnancy size. Instead, it helps in uterine contractions, which facilitate the expulsion of the placenta and reduce postpartum bleeding. The process of uterine involution, returning to prepregnancy size, is primarily managed by the natural decline of pregnancy hormones and autolysis of uterine tissue.

Choice B rationale

Oxytocin stimulates uterine contractions, which is its primary function during labor and after delivery. These contractions help deliver the baby during labor and facilitate the expulsion of the placenta. After delivery, oxytocin continues to induce contractions to minimize postpartum hemorrhage and aid uterine involution.

Choice C rationale

Oxytocin can activate the let-down reflex for breastfeeding, but it is not the primary expected outcome when administered IV after delivery. The main goal post-delivery is to manage uterine contractions to prevent hemorrhage and assist in expelling the placenta.

Choice D rationale

While oxytocin assists in expelling the placenta by stimulating contractions, this is not its primary use post-delivery. The placenta typically detaches and is delivered shortly after birth. Oxytocin's main role after delivery is to continue stimulating contractions to reduce bleeding and help the uterus return to a non-pregnant state.

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Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

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Correct Answer is B

Explanation

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

Correct Answer is B

Explanation

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Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?