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) Protect the fetal skin from amniotic fluid:
Vernix caseosa is a whitish, cheese-like substance that covers the skin of the fetus during the second and third trimesters of pregnancy. It plays an essential role in protecting the fetal skin from prolonged exposure to amniotic fluid, which can be irritating. Vernix also serves as a barrier that helps prevent water loss and protects against potential infections.

B) Promote normal peripheral nervous system development:
While the development of the peripheral nervous system is vital to fetal development, the presence of vernix caseosa is not directly related to promoting nervous system development. The vernix's primary function is to protect the skin, not influence neural development. Neural development occurs due to other factors, such as adequate nutrition and hormonal regulation during pregnancy.

C) Allow transport of oxygen and nutrients across the amnion:
Vernix caseosa does not play a role in transporting oxygen or nutrients across the amnion. Oxygen and nutrients are transferred to the fetus through the placenta and the umbilical cord. The amniotic sac, which contains amniotic fluid, provides a cushioning effect for the fetus, but the vernix itself does not participate in nutrient or oxygen exchange.

D) Regulate fetal temperature:
Vernix caseosa does not directly regulate fetal temperature. Fetal temperature regulation is mainly managed by the mother's body through thermoregulation and the umbilical blood flow. The vernix may provide some protection against temperature fluctuations after birth, but its primary function is to protect the skin, not to regulate temperature.

A. Prolactin B. Estrogen C. Progesterone D. Human placental lactogen E. Relaxin

Correct Answer is A

Explanation

A) Prolactin:
Prolactin is the primary hormone responsible for stimulating milk production in the postpartum period. In breastfeeding mothers, prolactin levels remain elevated, especially during the first few weeks after delivery, to support lactation. This hormone is released in response to suckling and is essential for maintaining a steady milk supply. Elevated prolactin levels help establish and maintain breastfeeding during the early postpartum period, even as other pregnancy-related hormones begin to decline.

B) Estrogen:
Estrogen levels drop sharply after childbirth, as the placenta is no longer present to produce this hormone. The decline in estrogen is one of the factors that helps initiate lactation. While estrogen rises later during the postpartum period as the body returns to its non-pregnant state, it is not elevated during the immediate postpartum period in breastfeeding women.

C) Progesterone:
Similar to estrogen, progesterone levels fall quickly after delivery. Progesterone is involved in maintaining pregnancy, and its levels decrease significantly once the placenta is delivered. A reduction in progesterone is one of the hormonal changes that triggers the onset of lactation. It does not remain elevated in the immediate postpartum period.

D) Human placental lactogen (hPL):
hPL is produced by the placenta during pregnancy to support fetal growth and prepare the breasts for lactation. However, after delivery, hPL levels decline rapidly because the placenta is expelled. It is not elevated in the immediate postpartum period.

E) Relaxin:
Relaxin is a hormone that helps to soften the cervix and relax the ligaments in preparation for childbirth. Its levels are elevated during pregnancy and drop significantly after delivery. It does not remain elevated in the postpartum period, particularly in breastfeeding women.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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