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.
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 D
Explanation
Choice A rationale
Obtaining blood cultures is not the first action to take in this situation. Blood cultures would be used to identify a bloodstream infection, which is not indicated by the client’s current symptoms.
Choice B rationale
Covering the lesion with a dressing is not the appropriate action. Herpes lesions are highly contagious, and covering them does not eliminate the risk of transmission during vaginal delivery.
Choice C rationale
Administering penicillin is not the appropriate action. Penicillin is an antibiotic used to treat bacterial infections, not viral infections like herpes.
Choice D rationale
Preparing for a cesarean section is the correct action. A cesarean section is recommended for women with active genital herpes lesions or prodromal symptoms at the time of labor to prevent transmission of the virus to the newborn during delivery.
Correct Answer is C
Explanation
Choice A rationale
Variance in blood pressure across extremities is not typically associated with ventricular septal defects (VSDs). VSDs are characterized by a hole in the heart that allows oxygen-rich blood to move back into the lungs instead of being pumped to the rest of the body.
Choice B rationale
Hypotension is not a common symptom of VSDs. Instead, these defects can cause increased blood pressure in the lungs due to the abnormal flow of blood.
Choice C rationale
Tachycardia, or a rapid heart rate, is a common symptom of VSDs, especially in cases where the defect is medium or large. This is because the heart needs to work harder to pump blood, leading to an increased heart rate.
Choice D rationale
While pulse oximetry readings within defined limits could be seen in small VSDs, in larger defects or those causing heart failure, oxygen saturation levels might be lower due to the abnormal circulation of blood.
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