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) Excessive uterine bleeding: A distended bladder can cause the uterus to become displaced to the right, preventing it from contracting effectively. This lack of uterine contraction can lead to uterine atony, which is a significant risk factor for excessive postpartum bleeding. When the uterus cannot contract well, it may result in continued
hemorrhage, which is a serious and immediate concern for postpartum patients.

B) A bladder rupture: While bladder rupture is a rare and severe complication, it is unlikely to occur in this situation. Bladder distention is a concern, but the most immediate danger is related to the uterus, not the bladder itself. A rupture would require significant trauma or extreme overdistention of the bladder, neither of which are described here.
C) Bladder wall atony: Bladder wall atony, where the bladder loses its ability to contract and expel urine, is not the most serious immediate consequence of bladder distention postpartum. While it may be uncomfortable and problematic, the main concern in this scenario is how bladder distention affects uterine contraction, which can lead to excessive bleeding.

D) Urinary tract infection: Although urinary retention can increase the risk of urinary tract infections (UTIs) due to incomplete bladder emptying, this is a less immediate and life-threatening concern compared to excessive bleeding. The primary concern in the immediate postpartum period is the potential for hemorrhage from uterine atony, which is worsened by bladder distention.

A. "I'll walk you to the bathroom and stay with you." B. ‘’I will get a bedpan for you." C. ‘’Leave your peri-pad in place after you use the restroom so I can check your bleeding when you get back." D. ‘’wait until I have had a chance to assess you first"

Correct Answer is A

Explanation

A) "I'll walk you to the bathroom and stay with you."
After delivery, the patient is at risk for orthostatic hypotension and falling, especially within the first few hours postpartum. Even though the patient feels alert and active, her body is still adjusting after childbirth, and she may be unsteady. The nurse should assist her to the bathroom and provide supervision for her safety. Walking the patient to the bathroom ensures she can safely get there while allowing the nurse to assess her mobility and vital signs if necessary.

B) "I will get a bedpan for you."
While a bedpan may be appropriate if the patient is unable to get out of bed, this response does not prioritize the patient's expressed desire to go to the bathroom. Since she is alert, active, and able to communicate, walking her to the bathroom is a safer and more appropriate option than offering a bedpan. Using a bedpan would also restrict her mobility unnecessarily.

C) "Leave your peri-pad in place after you use the restroom so I can check your bleeding when you get back."
This does not address the immediate concern of the patient’s safety in getting to the bathroom. The nurse's priority should be her safety and mobility right after delivery, especially as the patient is still recovering and may be at risk for fainting or falling.

D) "Wait until I have had a chance to assess you first."
While it is important to assess the patient’s physical state postpartum, the response here should focus on immediate safety rather than delaying her need to use the restroom. A full assessment can be conducted later, but it is not appropriate to restrict the patient's autonomy when she has already indicated the need to go to the bathroom.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A patient delivered 2 hours ago without medication. She is alert and active in bed but has not been out of bed yet. She states she needs to go the bathroom. What is the nurse's most appropriate response?

Correct Answer is A

Explanation

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