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.

Answer and Explanation

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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Correct Answer is D

Explanation

The correct answer is choice D. Presence of human chorionic gonadotropin (hCG) in blood.This is apositive sign of pregnancythat can only be attributed to a fetus.hCG is a hormone produced by the placenta that can be detected in blood or urine tests.

Choice A. Quickening.This is apresumptive sign of pregnancythat is based on the woman’s report of feeling fetal movements in her lower abdomen.This can occur at 16 weeks for second time moms and around 20 weeks for first time moms.However, this sign is not conclusive as other conditions can cause similar sensations.

Choice B. Uterine enlargement.This is aprobable sign of pregnancythat can be observed by the nurse or doctor through palpation.However, this sign does not mean 100% that a baby is growing in the uterus as it can be due to other causes such as fibroids or tumors.

Choice C. Urinary frequency.This is apresumptive sign of pregnancythat is based on the woman’s report of needing to urinate more often than usual.This can be caused by hormonal changes and increased blood volume during pregnancy.However, this sign is not definitive as other conditions such as urinary tract infections or diabetes can also cause frequent urination.

A. Making a loud sound within close range of the newborn. B. Firmly stroking the soles of the newborn’s feet with a thumb nail. C. Using the newborn’s hands to raise the baby from a supine position without supporting the head. D. Holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface.

Correct Answer is A

No explanation

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Just after a client delivers a baby who weighs 7 pounds (3.18 kg), what is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?

Correct Answer is D

Explanation

When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?

Correct Answer is A

The nurse instructs a postpartum patient in the use of a sitz bath. Which action by the patient indicates that the teaching was effective?

A patient comes to the antepartal clinic for her visit and provides the nurse with information. What piece of information places this patient at high risk for exposure to teratogenic agents?

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A patient diagnosed with preeclampsia is admitted to the hospital and prescribed magnesium sulfate therapy. What is the purpose of administering magnesium sulfate to this patient?

A nurse is caring for a patient who is in labor and is placed on a monitor.How should the nurse determine the duration of contractions?

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A woman gives birth to twin girls, one of whom is stillborn. Which nursing action would be least helpful in supporting the woman as she copes with her loss?

When a pregnant patient has genital herpes, for which complication is the patient at higher risk than the general population?