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 B
Explanation
The correct answer is choice B. Insulin amount needs will continue to increase throughout the second and third trimesters.This is because gestational diabetes is a form of diabetes that develops during pregnancy, usually during the 2nd or 3rd trimester.It is caused by hormonal changes that interfere with the action of insulin, leading to high blood sugar levels.As the pregnancy progresses, the placenta produces more hormones that increase insulin resistance, so the mother needs more insulin to keep her blood sugar within normal range.
Choice A is wrong because insulin amount needs will not remain stable during the third trimester.They will increase as the placenta grows and produces more hormones that cause insulin resistance.
Choice C is wrong because insulin amount needs will not decrease during the third trimester.They will increase as the placenta grows and produces more hormones that cause insulin resistance.
Choice D is wrong because insulin amount needs will not remain stable for the rest of the second and during the third trimesters.They will increase as the pregnancy progresses and the placenta produces more hormones that increase insulin resistance.
Normal ranges for blood sugar during pregnancy are: fasting < 95 mg/dL, 1 hour after meal < 140 mg/dL, 2 hours after meal < 120 mg/dL.
Correct Answer is C
Explanation
This is because a normal fetal heart rate is between 110 and 160 beats per minute, and the range of 136 to 143 indicates that the fetus is well-oxygenated and not experiencing hypoxia or acidosis. The nurse should reassure the patient and explain that fetal movement may decrease during labor due to the pressure of the contractions on the uterus and the fetus.
Choice A is wrong because asking the patient about alcohol consumption is irrelevant and insensitive.
Alcohol can affect fetal development and growth, but it does not directly affect fetal movement or heart rate.
Choice B is wrong because bloody vaginal discharge, or bloody show, is a normal sign of cervical dilation and effacement during labor.
It does not indicate fetal distress or placental abruption.
Choice D is wrong because explaining the relationship between anxiety and fetal movement does not address the patient’s concern or provide any factual information.
Anxiety can affect maternal perception of fetal movement, but it does not cause fetal movement to decrease.
The nurse should validate the patient’s feelings and provide factual reassurance.
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