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. Have a suction catheter available for use at delivery.This is because meconium-stained amniotic fluid indicates that the fetus has passed meconium (first stool) before birth, which can be a sign of fetal distress or hypoxia.Meconium can block the airways and cause breathing problems for the newborn, so suctioning the mouth and nose (or the trachea if needed) is important to prevent meconium aspiration syndrome.

Choice A is wrong because taking the mother’s vital signs every 15 minutes is not a specific intervention for meconium-stained amniotic fluid.

Vital signs should be monitored regularly during labor regardless of the fluid color.

Choice B is wrong because sending a specimen of the fluid to the laboratory for analysis is not a priority action.The color and consistency of the fluid can be observed by the nurse and documented.

The laboratory analysis will not change the immediate management of the newborn.

Choice D is wrong because preparing a slide of the fluid for fern testing is not relevant for meconium-stained amniotic fluid.

Fern testing is used to confirm the rupture of membranes by detecting a fern-like pattern of amniotic fluid under a microscope.It is not useful for assessing the presence or severity of meconium-stained amniotic fluid.

A. Decrease in body temperature. B. Maternal cardiac arrhythmias. C. Urinary retention. D. Insufficient relaxation of the uterus between contractions.

Correct Answer is D

Explanation

The correct answer is choice D. Insufficient relaxation of the uterus between contractions.This is also known astachysystoleorhyperstimulation, which can cause fetal distress and uterine rupture.Oxytocin is a hormone that stimulates uterine contractions, but it can also cause them to be too strong or too frequent if given in high doses or for too long.

Choice A is wrong because oxytocin does not decrease body temperature.

Choice B is wrong because oxytocin does not cause maternal cardiac arrhythmias.

Choice C is wrong because oxytocin does not cause urinary retention.

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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 patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

The mother of a 4-hour-old newborn reports to a nurse, “My son is producing breast milk.” The nurse’s response should be based on which understanding about newborn physiology? This is:.

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 patient has decided to bottle-feed her twins.The nurse should give this patient which instruction to help alleviate breast engorgement?

A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun. A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy. Which measure is an important part of this newborn’s care plan?

The nurse is assigned to care for the postpartum client during her shift. The nurse knows one of the most common risk factors for early (PPH) postpartum hemorrhage is uterine atony. When providing care, the nurse would plan to:.