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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. “Have you noticed any tenderness in your breasts?”
Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.
Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.
Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.
Choice C is wrong because spotting is not a sign of early pregnancy.
It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.
Correct Answer is B
Explanation
The correct answer is choice B. The administration route of terbutaline will be changed from intravenous to oral.
This is because terbutaline is a medication that can be used to suppress preterm labor by relaxing the uterine smooth muscle.It can be given subcutaneously or intravenously for acute episodes of preterm labor, but it is not recommended for long-term use due to the risk of serious maternal and fetal adverse effects.Therefore, if the client’s condition stabilizes, the administration route of terbutaline will be changed from intravenous to oral, which has a lower bioavailability and less systemic effects.
Choice A is wrong because terbutaline is not usually self-administered parenterally by the client at home.It requires a trained health professional to give it as a shot under the skin or through a vein.
Choice C is wrong because the client does not need to remain in a private room without visitors until she has been without contractions for 48 hours.
This is an unnecessary restriction that may increase the client’s stress and anxiety.
The client should be encouraged to have social support and emotional comfort during this time.
Choice D is wrong because the client should not ambulate in the hallway after 12 hours without contractions.
This may stimulate uterine activity and cause a recurrence of preterm labor.
The client should follow the provider’s instructions on bed rest and activity limitations.
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