A nurse is assessing a newborn immediately following a scheduled cesarean delivery.

Which of the following assessments is the nurse’s priority?

Respiratory distress

Acrocyanosis.

Accidental lacerations

Hypothermia

Answer and Explanation

The Correct Answer is A

A.   Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B.   Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D.   While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.

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Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

A. Document this as an expected finding. B. Call the provider to further assess the newborn. C. Prepare the newborn for transport to the NICU. D. Ask another nurse to verify the heart rate.

Correct Answer is A

Explanation

A. An apical heart rate of 130/min is within the normal range for a newborn and does not require immediate intervention.
B. Contacting the provider is not necessary as the heart rate is within the expected range.
C. Preparing for NICU transport is not warranted based on a heart rate of 130/min.
D. Verifying the heart rate with another nurse is unnecessary for a heart rate within the normal range.

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A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is C

Explanation

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is assessing a newborn immediately following a scheduled cesarean delivery.

Which of the following assessments is the nurse’s priority?