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 A

Explanation

The correct answer is choice A. The patient uses the sitz bath three times a day.This indicates that the patient understands the benefits of sitz baths for postpartum recovery, such as pain relief, increased blood flow, relaxation, cleansing, and itch relief.Sitz baths can be done with warm or cool water, depending on the preference of the patient.However, they should not be done for more than 20 minutes at a time, as this can cause the stitches in the perineal area to fall apart.

Therefore, choice C is wrong.Choice B is also wrong, as there is no evidence that alternating between warm and cool sitz baths has any additional benefits or effects.

Choice D is wrong, as tightening and relaxing the perineal muscles during a sitz bath is not recommended.This can cause more pain and irritation to the area, and interfere with the healing process.The normal ranges for sitz baths are two to four times a day for up to 20 minutes each.

A. “Did you know that your baby’s development is affected by the type of drugs you use during the pregnancy?”. B. “Are you aware that using nonprescription medication during pregnancy may be regarded as child abuse?”. C. “What drugs have you used during your pregnancy?”. D. “Have you ever used street drugs?”.

Correct Answer is C

Explanation

The correct answer is choice C. “What drugs have you used during your pregnancy?”.

This question is open-ended and nonjudgmental, which encourages the patient to disclose more information about her drug use.

The nurse can then assess the type, frequency, and amount of drugs used and plan appropriate interventions.

Choice A is wrong because it is a closed-ended question that can be answered with a yes or no, and it implies criticism of the patient’s behavior, which may make her defensive and less willing to cooperate.

Choice B is wrong because it is also a closed-ended question that can be answered with a yes or no, and it may frighten or anger the patient, who may not be aware of the legal implications of her drug use.

Choice D is wrong because it is too vague and may not cover all the possible drugs that the patient may have used, such as prescription medications, alcohol, or tobacco.

It also labels the patient as a drug user, which may offend her or make her feel ashamed.

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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

The nurse instructs a postpartum patient in the use of a sitz bath. Which action by the patient indicates that the teaching was effective?

Correct Answer is A

Explanation

The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?

Correct Answer is C

Explanation

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

A nurse is caring for a patient who is 40 weeks pregnant. Which finding would indicate the need for a cesarean delivery?

he nurse instructs a woman who is attending the infertility clinic about strategies designed to facilitate conception. Which statement by the patient would indicate that she understands the instructions?

A patient who is 38 weeks pregnant and has tested positive for a chlamydial infection asks the nurse to discuss the baby's risk of becoming infected.Which information should the nurse include in discussion with the patient?

A nurse is caring for a newborn who is placed in a neutral thermal environment.What is the desired outcome of this measure?

A 23-year-old primigravida who appears to be in her third trimester of pregnancy comes to the labor and delivery unit reporting acute abdominal pain. She has had no prenatal care. Which assessment should the nurse do first?

The nurse at the antepartal clinic reviews four patients’ charts. Which patient is at increased risk for an ectopic pregnancy?