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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Wear a supportive bra.This will help suppress lactation and reduce the discomfort of engorgement.
The other choices are wrong because:
• Choice A. Manually express colostrum as necessary.This will stimulate milk production and prolong engorgement.
• Choice B. Apply hot compresses to the breasts.This will increase blood flow and swelling in the breasts and worsen engorgement.
• Choice C. Massage the breast tissue surrounding the areola.This will also stimulate milk production and prolong engorgement.
Normal ranges for breast engorgement are not applicable as it is a subjective experience that varies among women.However, some signs of engorgement include firm, tender, swollen breasts, flat or inverted nipples, and low-grade fever.Engorgement usually resolves within 24 to 36 hours after it begins.
Correct Answer is C
Explanation
The correct answer is choice C. The reason for the patient’s visit at this time.
This information will help the nurse assess the patient’s motivation, readiness, and urgency for contraception.
It will also help the nurse tailor the education and counseling to the patient’s specific needs and preferences.
Choice A is wrong because the amount of sexual experience that the patient has had is not relevant to determine the patient’s knowledge base.
It may also make the patient feel uncomfortable or judged.
Choice B is wrong because the type of contraceptive that the patient’s friends are using is not a reliable source of information.
Different methods may have different advantages and disadvantages for different people.
The nurse should provide evidence-based information and guidance on various options.
Choice D is wrong because the method of contraception that the patient believes will provide protection from sexually transmitted diseases may not be accurate or effective.
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