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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
No explanation
Correct Answer is D
Explanation
The correct answer is choice D. Rest on your side as much as possible.This is because resting on the side can improve blood flow to the placenta and lower blood pressure.It can also reduce the risk of supine hypotensive syndrome, which occurs when the weight of the uterus compresses the inferior vena cava and reduces venous return.
Choice A is wrong because spicy foods have no effect on blood pressure or pregnancy outcomes.Choice B is wrong because limiting fluid intake can lead to dehydration and increase blood viscosity, which can worsen hypertension.Choice C is wrong because urinating frequently does not lower blood pressure or prevent complications of pregnancy-induced hypertension.
Pregnancy-induced hypertension (PIH) is a condition that causes high blood pressure during pregnancy.It can lead to serious problems for both the mother and the baby, such as pre-eclampsia, eclampsia, placental abruption, fetal growth restriction, and stillbirth.
Women with PIH should follow their doctor’s advice on medication, diet, exercise, and monitoring.They should also report any symptoms of pre-eclampsia, such as severe headache, blurred vision, abdominal pain, or swelling.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.