A nurse is assisting with the care of a client who is beginning the third stage of labor.
Which of the following actions should the nurse take first?
Check the newborn's axillary temperature.
Dry the newborn with clean towels.
Apply the identification bands to the newborn and the mother.
Allow private bonding time for the parents and newborn.
The Correct Answer is B
Choice A rationale
Checking the newborn's axillary temperature is important for thermoregulation, but immediate drying takes precedence to prevent heat loss through evaporation and convection. A stable temperature range for a newborn is typically 36.5°C to 37.5°C (97.7°F to 99.5°F). Hypothermia can lead to increased oxygen consumption and metabolic acidosis in newborns.
Choice B rationale
Drying the newborn immediately after birth is crucial for preventing evaporative heat loss. The wet surface of the newborn's skin, exposed to cooler ambient temperatures, can rapidly cool the infant through evaporation, leading to hypothermia. This is a primary intervention for neonatal thermoregulation.
Choice C rationale
Applying identification bands is a safety measure to prevent infant abduction or mix-up, but it is not the most immediate physiological need for the newborn after birth. While important, it can be done after ensuring the newborn's thermal stability.
Choice D rationale
Allowing private bonding time is beneficial for parent-infant attachment and can promote breastfeeding, but ensuring the newborn's physiological stability, particularly thermoregulation, takes precedence immediately after birth. Bonding can occur once initial assessments and interventions are completed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}
Explanation
? Rationales for Each Condition
1️⃣ Neonatal abstinence syndrome (NAS)
Definition: NAS is a withdrawal syndrome in newborns caused by in utero exposure to opioids or other substances. It typically presents within 24–72 hours after birth.
Findings and Scientific Explanation:
- Cry characteristics: A high-pitched, inconsolable cry is a hallmark of NAS due to autonomic nervous system dysregulation.
- Nasal findings: Sneezing and nasal stuffiness are common due to increased autonomic activity and are not typically seen in hypoglycemia.
- Tremor: Tremors, especially when undisturbed, are due to central nervous system irritability from opioid withdrawal.
- Maternal urine drug screen: A positive result for opioids confirms in utero exposure, supporting a diagnosis of NAS.
- Respiratory rate: Tachypnea (e.g., 65/min on Day 3) is common in NAS due to increased metabolic demand and autonomic instability. Normal neonatal respiratory rate is 30–60/min.
2️⃣ Hypoglycemia
Definition: Neonatal hypoglycemia is defined as a plasma glucose concentration less than 40–45 mg/dL in the first 24 hours of life.
Findings and Scientific Explanation:
- Cry characteristics: Hypoglycemia may cause irritability or weak cry due to neuroglycopenia.
- Tremor: Tremors or jitteriness can result from adrenergic stimulation in response to low glucose levels.
- Respiratory rate: Tachypnea may occur as a compensatory response to metabolic acidosis secondary to hypoglycemia. The newborn had a glucose of 35 mg/dL on Day 1, which is below the normal range (>40–45 mg/dL).
Correct Answer is B
Explanation
Choice A rationale
Vaginal fluid with a pH of 5.3 is acidic and falls within the normal range for vaginal secretions, which are typically between 3.8 and 4.5. Amniotic fluid is alkaline, with a pH of 7.0 to 7.5. Therefore, an acidic pH does not indicate premature rupture of membranes.
Choice B rationale
Nitrazine paper turning dark blue indicates an alkaline pH, which is characteristic of amniotic fluid (pH 7.0-7.5). The presence of alkaline fluid in the vagina suggests premature rupture of membranes, as normal vaginal secretions are acidic.
Choice C rationale
A positive ferning test, where amniotic fluid dries in a fern-like pattern on a microscope slide, indicates the presence of amniotic fluid. A negative ferning test would suggest that the fluid is not amniotic fluid.
Choice D rationale
Nitrazine paper turning yellow indicates an acidic pH, which is consistent with normal vaginal secretions or urine. This finding would suggest that the fluid is not amniotic fluid, as amniotic fluid is alkaline and would turn the paper blue or dark blue.
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