Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

Maintaining the infants’ airways.

Keeping the infants in a warm, draft-free environment.

Placing identification bands on the infants.

Monitoring the infants’ vital signs.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery. This is because twins are more likely to be born early and need special care after birth than single babies. They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.

The nurse should assess the infants’ respiratory status and intervene as needed.

Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well. Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.

Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.

The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.

Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.

The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.

Normal ranges for vital signs in newborns are:

• Heart rate: 100 to 160 beats per minute

• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic

• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)

• Blood sugar: 40 to 80 mg/dL

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Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

A. Offer her the opportunity for counseling to help her grieve. B. Encourage the woman to hold the deceased twin as well as the living twin. C. Remind her that she should be happy that one child survived and is healthy. D. Assist the woman to take pictures of both babies.

Correct Answer is C

Explanation

The correct answer is choice C. Reminding her that she should be happy that one child survived and is healthy is the least helpful nursing action in supporting the woman as she copes with her loss.

This statement minimizes her grief and implies that she should not feel sad about the deceased twin.

It also disregards her attachment to both babies and her need to mourn the loss of one of them.

Choice A is wrong because offering her the opportunity for counseling to help her grieve is a helpful nursing action that recognizes her emotional distress and provides her with professional support.

Choice B is wrong because encouraging the woman to hold the deceased twin as well as the living twin is a helpful nursing action that allows her to acknowledge and bond with both babies and to create memories that may facilitate healing.

Choice D is wrong because assisting the woman to take pictures of both babies is a helpful nursing action that provides her with tangible mementos of her twins and honors their

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Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

A client who is twO weeks postpartum calls the office and tells a nurse, "l am havinga small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

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A client who had pregnancy-induced hypertension (PIH) is now postpartum. A nurse should closely monitor this client for which complication?

A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

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