A full term newborn was just born. Which nursing intervention is important for the nurse to perform first?

Dry the infant throughly and place on mom skin to skin

Determine Apgar Score.

Encourage mother to begin breastfeeding.

Administer medication for eye prophylaxis.

Answer and Explanation

The Correct Answer is A

A) Dry the infant thoroughly and place on mom skin to skin:
The priority intervention for a newborn immediately after birth is to dry the infant thoroughly and promote skin-to-skin contact with the mother. Drying the infant helps prevent heat loss, a major concern for newborns as they are at risk of hypothermia due to their large body surface area relative to their weight. Skin-to-skin contact not only helps maintain the newborn's body temperature but also promotes bonding, regulates heart rate, and supports breastfeeding initiation. This is the most critical step in the immediate post-birth period.
B) Determine Apgar Score:
While assessing the newborn with the Apgar score is an important task, it is usually done within the first minute and five minutes after birth. However, ensuring the infant’s warmth and stability by drying and placing the baby on the mother's chest should take priority. The Apgar score can be recorded after ensuring that the newborn is stable and appropriately warmed.

C) Encourage mother to begin breastfeeding:
Encouraging breastfeeding is an important aspect of newborn care, as it provides essential nutrients and promotes bonding. However, skin-to-skin contact and ensuring the infant is warm and stable take precedence over breastfeeding initiation. Once the baby is stable and has been dried and placed on the mother’s chest, breastfeeding can begin naturally.

D) Administer medication for eye prophylaxis:
Administering eye prophylaxis (typically erythromycin or tetracycline ointment) is important to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia. However, this is a secondary concern compared to maintaining the newborn's temperature and ensuring initial bonding. The medication can be administered after the initial stabilizing interventions have been completed.

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Correct Answer is A

Explanation

A) Developing Prolactin Receptor Sites:
The first 1-5 days postpartum are critical for breastfeeding success because this period is when the prolactin receptor sites in the mother's breast tissue are being established. Prolactin is the hormone responsible for milk production, and the more prolactin receptor sites developed, the more efficiently the body can respond to the baby’s sucking and produce milk. This is the foundation for a successful breastfeeding relationship, as proper stimulation in these early days encourages the long-term supply of milk.

B) Decreasing Oxytocin:
Oxytocin is the hormone responsible for milk ejection (let-down) and is crucial for breastfeeding. In the early postpartum period, oxytocin levels are actually high and remain important for milk release, not decreasing. A decrease in oxytocin would impair milk ejection, which could affect breastfeeding success.

C) Decreasing Estrogen:
Estrogen levels drop significantly after delivery, which is part of the process that allows milk production to take precedence over pregnancy-related hormones. However, the drop in estrogen is more of a secondary event in breastfeeding success compared to the development of prolactin receptor sites. Estrogen primarily impacts lactation later, such as with the onset of menstruation.

D) Increasing Estrogen:
Estrogen levels rise during pregnancy, but they begin to decrease rapidly after birth. Higher levels of estrogen inhibit lactation during pregnancy, which is why the postpartum drop in estrogen is important for milk production to commence. However, an increase in estrogen would actually hinder the initiation of lactation and is not a factor in the success of breastfeeding in the early postpartum period.

A. The woman has laceration B. The woman had her fourth baby C. The woman received epidural anesthesia D. The woman had a vacuum assisted birth

Correct Answer is A

Explanation

A. The woman has a laceration:
The orders for perineal ice packs, sitz baths, and a stool softener suggest that the woman may have sustained perineal trauma, such as a laceration, during childbirth. Ice packs are used initially to reduce swelling and discomfort, while a sitz bath helps with healing and soothing of the perineal area. Stool softeners are prescribed to prevent straining during bowel movements, which could worsen the discomfort of a laceration. These interventions are commonly recommended for women who experience perineal lacerations during vaginal delivery.

B. The woman had her fourth baby:
While the fact that this is the woman’s fourth pregnancy may influence her overall recovery, it is not directly correlated with the orders for ice packs, sitz baths, and stool softeners. Women who have had multiple children may be at a higher risk for perineal trauma due to the stretching of tissues, but this specific care plan is more likely related to a perineal injury, not the number of previous births.

C. The woman received epidural anesthesia:
Epidural anesthesia may be used to manage pain during labor, but it does not directly necessitate the use of ice packs, sitz baths, or stool softeners. While epidurals can sometimes lead to difficulty with bladder or bowel control, they do not typically cause perineal lacerations or require these specific interventions unless there is another issue, such as a laceration, that needs attention.

D. The woman had a vacuum-assisted birth:
Vacuum-assisted births can cause perineal trauma, including lacerations or hematomas, but the order for perineal care (ice packs, sitz baths, stool softeners) is not exclusively linked to vacuum assistance. The woman may have had a laceration during a vacuum-assisted delivery, but it is the laceration itself, rather than the use of the vacuum, that most directly correlates with these interventions. Therefore, the priority care focus is still on addressing the potential for perineal laceration.

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A full term newborn was just born. Which nursing intervention is important for the nurse to perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Day 1 - 5 postpartum is significant in breastfeeding success due to what process?

Correct Answer is A

Explanation

A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of sitz bath TID, and a stool softener. What information is most closely correlated with these orders?

Correct Answer is A

Explanation

Which of the following nursing interventions will promote comfort for a client with a labial first degree laceration? Select all that apply.

Name 3 nursing interventions that promote stabilization of the newborn immediately after birth:

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