The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?

Hypoglycemia.

Bleeding tendencies.

Heat loss.

Fluid balance.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Hypoglycemia, or low blood sugar, is a concern in newborns, but it is not the most immediate concern within the first minutes after delivery.
Choice B rationale
While newborns do have certain bleeding tendencies due to immature clotting mechanisms, this is not the immediate priority in the first minutes after birth.
Choice C rationale
The priority issue that the nurse should address to ensure the newborn’s survival is heat loss.
Newborns are at high risk of heat loss and maintaining their body temperature is crucial. This is because they have a large body surface area relative to their weight and their temperature regulation mechanism is not fully developed.
Choice D rationale
Fluid balance is important in newborns, but it is not the immediate concern in the first minutes after birth. The initial focus is on establishing respiration and maintaining body temperature.

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Correct Answer is B

Explanation

Choice A rationale

Preparing a vacuum is not the first action to take when the fetal head retracts against the perineum during the second stage of labor.

Choice B rationale

Applying suprapubic pressure can help guide the baby’s head out. This is a common practice during the second stage of labor when the baby’s head retracts against the perineum.

Choice C rationale

Applying fundal pressure is not typically done when the fetal head retracts against the perineum. Fundal pressure can be used to assist in the delivery of the baby, but it’s not the first action to take in this situation.

Choice D rationale

Preparing forceps is not the first action to take when the fetal head retracts against the perineum. Forceps are used to assist in the delivery of a baby, but only when necessary.

A. To prevent herpes infection B. To prevent eye infections C. To clear the infant’s vision D. To dilate the pupil so the red reflex can be visualized E. To dilate the pupil so the red reflex can be viWhat would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

Choice A rationale
While it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.

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The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What is the priority issue that the nurse should address to ensure the newborn’s survival?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the second stage of labor, the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. What action should the nurse anticipate performing to assist the healthcare provider?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes. He asks the nurse about the purpose of the ointment. What would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

After a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse is preparing the family for discharge. Monitor the infant for response to auditory stimuli.

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The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back. Which parental statement indicates understanding of the procedure?

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The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?