Just after a client delivers a baby who weighs 7 pounds (3.18 kg), what is the priority nursing action?

Obtain a serum sample.

Dry off the newborn.

Assess the newborn’s Moro reflex.

Obtain the newborn’s footprints.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.

The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress. Drying off the newborn also stimulates breathing and crying, which helps clear the airways.

Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.

Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination. Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.

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Correct Answer is B

Explanation

The correct answer is choice B. The patient’s uterine contraction pattern is enhanced.Prostaglandin E2 gel is used to induce labor by ripening and dilating the cervix and stimulating uterine contractions.The effectiveness of the gel can be measured by the frequency, duration and intensity of the contractions.

A stronger and more regular contraction pattern indicates that the gel is working and labor is progressing.

Choice A is wrong because cervical dilation is not the only indicator of labor induction.Cervical dilation can occur without contractions or with weak and irregular contractions, which means that labor is not established yet.

Choice C is wrong because cervical softening (or effacement) is a prerequisite for cervical dilation, but it does not necessarily mean that labor has started.Cervical softening can occur weeks before labor or even during pregnancy.

Choice D is wrong because uterine softening (or relaxation) is the opposite of what prostaglandin E2 gel is supposed to do.Uterine softening reduces the contractility and tone of the uterus, which can lead to prolonged labor or fetal distress.

A. Making a loud sound within close range of the newborn. B. Firmly stroking the soles of the newborn’s feet with a thumb nail. C. Using the newborn’s hands to raise the baby from a supine position without supporting the head. D. Holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface.

Correct Answer is A

Explanation

The correct answer is choice A.Making a loud sound within close range of the newborn will elicit the Moro reflex, which is an involuntary protective motor response against abrupt disruption of body balance or extremely sudden stimulation.The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually).

Choice B is wrong because firmly stroking the soles of the newborn’s feet with a thumb nail will elicit the Babinski reflex, which is a normal response in infants that involves fanning out and curling of the toes.

Choice C is wrong because using the newborn’s hands to raise the baby from a supine position without supporting the head will elicit the traction response, which is a normal response in infants that involves flexion of the elbows and shoulders.

Choice D is wrong because holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface will elicit the stepping reflex, which is a normal response in infants that involves alternating steps with each foot.

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Just after a client delivers a baby who weighs 7 pounds (3.18 kg), what is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician prescribes prostaglandin (PGE2) gel for a patient being admitted for induction of labor. Which finding would best indicate that the prostaglandin gel is effective?

Correct Answer is B

Explanation

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

Correct Answer is A

Explanation

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