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. Encourage the client to drink cold, carbonated fluids throughout the day.This helps to relieve the shoulder pain caused by the carbon dioxide gas used to inflate the abdomen during laparoscopy.
The gas irritates the diaphragm, which refers pain to the shoulder.Drinking cold, carbonated fluids can help expel the gas and reduce the pain.
Choice A is wrong because an abdominal binder is not necessary for a laparoscopic procedure.It is more commonly used for abdominal surgeries that involve a large incision.
Choice B is wrong because a rocking chair is not helpful for a client who had a laparoscopic BTL.It is more useful for a client who had a vaginal delivery to promote comfort and uterine involution.
Choice C is wrong because keeping the head of the bed flat for six hours is not indicated for a laparoscopic BTL.It may increase the risk of venous thromboembolism and pulmonary embolism due to prolonged immobility.The client should be encouraged to ambulate as soon as possible after surgery.
Correct Answer is C
Explanation
A nonstress test (NST) is a test in pregnancy that measures fetal heart rate and reaction to movement.Your pregnancy care provider performs a nonstress test to make sure the fetus is healthy and getting enough oxygen.It’s safe and painless, and gets its name because it puts no stress (nonstress) on you or the fetus.
Choice A is wrong because a nonstress test does not measure the mother’s ability to tolerate the discomfort of labor.A stress test is a different procedure that involves stimulating contractions and monitoring how the fetus responds.
Choice B is wrong because a nonstress test does not measure fetal lie, which is the position of the fetus in the uterus.
Fetal lie is usually determined by ultrasound or physical examination.
Choice D is wrong because a nonstress test does not measure maternal readiness for labor.A nonstress test typically happens after 28 weeks of pregnancy, when fetal heart rate starts reacting to movements.
Maternal readiness for labor is assessed by other factors, such as cervical dilation and effacement.
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