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

Heat loss.

Hypoglycemia.

Fluid balance.

Bleeding tendencies.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss.

Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.

Choice B rationale

While hypoglycemia is a concern in newborns, especially those born to mothers with diabetes, it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice C rationale

Fluid balance is important in newborns, but it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

Choice D rationale

While newborns do have immature clotting mechanisms, making them more prone to bleeding tendencies, this is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.

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Correct Answer is D

Explanation

Choice A rationale

While monitoring the client’s vital signs is an important part of postpartum care, it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice B rationale

Notifying the healthcare provider is important, but it would not be the first action to take. The nurse should first attempt to address the issue.

Choice C rationale

Inspecting the perineal pad could provide information about the client’s postpartum bleeding, but it would not directly address the issue of a boggy uterus that is displaced above and to the right of the umbilicus.

Choice D rationale

Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.

A. Remain on clear liquids until the vomiting subsides. B. Take nothing by mouth until there is no more nausea. C. Come to the clinic to be seen by a healthcare provider. D. Make an appointment at the clinic if a fever occurs.

Correct Answer is C

Explanation

Choice A rationale

While remaining on clear liquids until the vomiting subsides may seem like a reasonable approach, it may not be the best course of action for a pregnant woman who has been vomiting for 24 hours. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus.

Choice B rationale

Taking nothing by mouth until there is no more nausea is not advisable in this situation. Nausea can persist even after vomiting has stopped, and it’s important for the woman to stay hydrated and nourished.

Choice C rationale

The best course of action in this situation is for the woman to come to the clinic to be seen by a healthcare provider. This is because prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus. In addition, the healthcare provider can assess the woman’s condition and provide appropriate treatment.

Choice D rationale

Making an appointment at the clinic if a fever occurs is not the best advice in this situation. While it’s important to seek medical attention if a fever develops, the woman should not wait for this to happen before seeking help. Prolonged vomiting can lead to dehydration and electrolyte imbalances, which can be harmful to both the mother and the fetus, and should be addressed promptly.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

Correct Answer is D

Explanation

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

Correct Answer is C

Explanation

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A neonate, who is one day old, develops a cephalhematoma.Which common complication should the nurse assess this neonate for?

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The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

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