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 C

Explanation

The correct answer is choice C. Remind the patient that the nurse will stay with her during the examination.

This measure would help reduce the patient’s anxiety by providing emotional support and reassurance.

The patient may feel scared, embarrassed, or vulnerable during the pelvic examination, especially since she is young and pregnant.

Having a trusted person with her can help her cope with these feelings.

Choice A is wrong because it may imply that the examination will be painful and increase the patient’s anxiety.

Choice B is wrong because it may make the patient feel like she is not being treated as an individual and that her concerns are not valid.

Choice D is wrong because it may make the patient feel rushed or pressured and not allow her to ask questions or express her feelings.

A. "The discharge that you are describing is normal at this time." B. "Have you been running a fever?". C. “It sounds as if you have begun to ovulate again." D. "Are you taking iron supplements?".

Correct Answer is A

Explanation

The correct answer is choice A: “The discharge that you are describing is normal at this time.” This is because the client is experiencing lochia serosa, which is a brownish discharge that occurs from about day 4 to day 10 postpartum.

Lochia serosa is composed of old blood, serum, leukocytes, and tissue debris.

It indicates that the placental site is healing and the uterus is involuting.

Choice B is wrong because fever is a sign of infection, not normal lochia.

Choice C is wrong because ovulation usually does not resume until 6 weeks postpartum for nonbreastfeeding women and later for breastfeeding women.

Choice D is wrong because iron supplements do not affect lochia color or amount.

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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

A 14-year-old patient visits the antepartal clinic because she has missed three menstrual periods.The patient is to have a pelvic examination. In addition to explaining the procedure, which measure would best help reduce the patient’s anxiety?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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