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 D
Explanation
The correct answer is choice D. Cesarean delivery.A pregnant patient with genital herpes is at higher risk of transmitting the infection to the baby during vaginal delivery, especially if there is an active outbreak near the time of birth.This can cause serious complications for the baby, such as brain damage, eye problems, or even death.Therefore, a cesarean delivery is recommended to avoid contact between the baby and the genital lesions.
Choice A is wrong because forceps-assisted second stage of labor is not a complication of genital herpes.
It is a method of assisted delivery that may be used for various reasons, such as fetal distress, maternal exhaustion, or abnormal presentation.
Choice B is wrong because precipitous delivery, which means a very fast labor and delivery, is not a complication of genital herpes.
It may be caused by factors such as multiparity, strong contractions, or previous rapid deliveries.
Choice C is wrong because prolonged first phase of labor, which means a slow dilation of the cervix, is not a complication of genital herpes.
It may be caused by factors such as ineffective contractions, large fetal size, or malposition.
Correct Answer is C
Explanation
The correct answer is choice C.Adolescents need more protein than older pregnant women because they are still growing themselves and need to support the growth of the baby and the placenta.Protein can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.
Choice A is wrong because adolescents need more supplemental iron than older women, not less.This is because they have lower iron stores due to rapid growth and menstruation.Iron deficiency can cause anemia and increase the risk of infections and bleeding.Iron can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.
Choice B is wrong because adolescents need more carbohydrates than older women, not less.Carbohydrates provide energy for the mother and the baby and spare protein for other functions.Carbohydrates can be found in grains, fruits, vegetables, and dairy products.
Choice D is wrong because adolescents need the same amount of vitamin C as older pregnant women, which is 85 milligrams per day.Vitamin C helps with wound healing, collagen formation, iron absorption, and immune function.Vitamin C can be found in citrus fruits, tomatoes, peppers, broccoli, potatoes, and fortified juices.
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