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. Apply ice to her perineal area.This is because ice can help reduce swelling and pain in the episiotomy wound, which is a cut made in the tissue between the vagina and anus during childbirth.Ice should be applied for the first 24 to 48 hours after delivery.
Choice A is wrong because Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are not recommended for the first 12 hours after an episiotomy.They can increase blood flow and inflammation in the area, and may interfere with healing.
Choice C is wrong because keeping her hips slightly elevated can cause pressure on the episiotomy wound and increase discomfort.It can also affect blood circulation and drainage in the area.
Choice D is wrong because observing her perineal area for signs of infection is not a nursing action that should be included in her plan of care for the first 12 hours.Infection is rare in episiotomy wounds, and signs of infection usually appear after 24 hours or later.However, the nurse should teach the patient how to keep the area clean and dry, and when to report any signs of infection, such as fever, pus, or foul-smelling discharge.
Normal ranges for episiotomy healing are:
• Stitches dissolve within 2 to 4 weeks
• Pain and swelling subside within a few days to a week
• Wound heals completely within 4 to 6 weeks
Correct Answer is A
Explanation
The correct answer is choice C. Caloric intake should be 300 calories above the suggested non-pregnant caloric intake.This is because women with gestational diabetes need to meet the nutritional needs of pregnancy and also control their blood glucose levels.
Choice A is wrong because carbohydrates should make up about 45% of the total dietary intake for women with gestational diabetes, not 25%.
Carbohydrates are important for providing energy and nutrients for the mother and the baby.
Choice B is wrong because animal protein can be included in the pre-bedtime snack as long as it is combined with some carbohydrates.
Protein can help prevent low blood glucose levels during the night.
Choice D is wrong because sugar substitutes do not help to control blood glucose levels.They may also have adverse effects on the baby’s development.Women with gestational diabetes should limit their intake of added sugars and choose foods with natural sugars instead.
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