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 ["0.5"]

Explanation

Given:

Desired dose: Vitamin K 0.5 mg IM

Available concentration: Vitamin K 1 mg/1 mL

To find:

Volume to administer (in mL)

Step 1: Set up the proportion

We can use the following proportion to solve the problem:

(Desired dose) / (Available concentration) = Volume to administer

Step 2: Substitute the values

Plugging in the given values, we get:

(0.5 mg) / (1 mg/1 mL) = Volume to administer

Step 3: Simplify

To simplify, we can invert the denominator and multiply:

(0.5 mg) x (1 mL / 1 mg) = Volume to administer

The "mg" units cancel out, leaving us with:

(0.5 x 1 mL) / 1 = Volume to administer

Step 4: Calculate

Performing the multiplication and division, we get:

0.5 mL / 1 = Volume to administer

0.5 mLVolume to administer

A. The urethra, bladder and urinary meatus is edematous B. She has decreased sensitivity to fluid pressures after a vaginal birth C. At 12 hours postpartum she will begin diuresing D. There is no cause for concern as long as the patient urinates once shift E. A full bladder can lead to postpartum hemorrhage

Correct Answer is ["A","B","C","E"]

Explanation

A) The urethra, bladder, and urinary meatus are edematous:
Postpartum women often experience edema in the urethra, bladder, and urinary meatus due to the pressure exerted during delivery. This swelling can make it difficult for the woman to feel the urge to urinate, even when her bladder is full. Encouraging her to urinate every 2 hours helps prevent overdistension of the bladder, which can lead to urinary retention and other complications.

B) She has decreased sensitivity to fluid pressures after a vaginal birth:
After childbirth, especially a vaginal birth, the pelvic floor and surrounding tissues can be numb or less sensitive due to trauma, swelling, and the effects of anesthesia. This decreased sensitivity makes it harder for the woman to sense when she needs to urinate. Encouraging regular voiding even without the urge helps to prevent urinary retention, which is common in the immediate postpartum period.

C) At 12 hours postpartum, she will begin diuresing:
Diuresis, the process of excreting excess fluid retained during pregnancy, typically begins within 12 hours postpartum. This increased urine output can make it even more important for the mother to void regularly to prevent urinary retention. If the bladder is not emptied regularly, it can lead to discomfort and increase the risk of complications like bladder distention or infection.

D) There is no cause for concern as long as the patient urinates once per shift:
This is not true. A postpartum woman should void more frequently than once per shift (which is about every 8 hours). Urinating only once every shift can lead to urinary retention, bladder overdistension, and possible infection. The recommendation to urinate every 2 hours helps ensure proper bladder emptying and reduces the risk of complications.

E) A full bladder can lead to postpartum hemorrhage:
A full bladder can indeed contribute to postpartum hemorrhage (PPH). An overdistended bladder can displace the uterus, preventing it from contracting effectively after delivery. This can increase the risk of excessive bleeding. Regular voiding helps prevent bladder distention and supports uterine contraction, thereby reducing the risk of hemorrhage.

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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

The nurse is going to administer a dose of Vitamin K (Aquamephyton) 0.5mg IM to a newborn. Available: Vitamin K 1 mg/1ml. How many mLs would the nurse administer? (Please answer numerically only)

Correct Answer is ["0.5"]

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is caring for a postpartum patient who experienced a second-degree laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?

You are assessing the baby and notice that their hands and feet are bluish-purple. You:

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The nurse has received shift report on the postpartum unit. Which patient should the nurse see first?

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

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Which finding 12 hours after birth requires further assessment?

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion?