A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

Confirm identification and apply a bracelet.

Examine the newborn for birth defects.

Dry the newborn.

Conduct a gestational age assessment.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Dry the newborn.

Choice A rationale:

Confirming identification and applying a bracelet is important for ensuring the newborn’s identity and preventing mix-ups, but it is not the immediate priority right after birth.

Choice B rationale:

Examining the newborn for birth defects is crucial for identifying any immediate health concerns, but it should be done after initial stabilization measures like drying and warming the newborn.

Choice C rationale:

Drying the newborn is the first action the nurse should take immediately after delivery. This helps to prevent heat loss and maintain the newborn’s body temperature, which is critical for their survival and well-being.

Choice D rationale:

Conducting a gestational age assessment is important for determining the newborn’s maturity and potential health risks, but it is not the immediate priority right after birth.

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Correct Answer is A

Explanation

Choice A rationale :

The correct answer is A. Calcium gluconate. The nurse should administer calcium gluconate in this situation because the client's respiratory rate is 8/min, which indicates respiratory depression. Magnesium sulfate is known to cause respiratory depression as a side effect, and calcium gluconate is the antidote for magnesium sulfate toxicity. Calcium gluconate works by antagonizing the effects of magnesium on the neuromuscular junction and restoring normal respiratory function. Prompt administration of calcium gluconate can help reverse respiratory depression and prevent further complications.

Choice B rationale

Naloxone. Naloxone is not the correct choice in this scenario. Naloxone is an opioid antagonist and is used to reverse the effects of opioids in cases of opioid overdose. Since the client is receiving magnesium sulfate, which is not an opioid, naloxone would not be effective in reversing the respiratory depression caused by magnesium sulfate. Administering naloxone in this situation would not address the underlying cause and may not improve the client's condition.

Choice C rationale

Flumazenil. Flumazenil is not the correct choice in this situation. Flumazenil is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines in cases of benzodiazepine overdose. Since the client is not receiving benzodiazepines but rather magnesium sulfate, flumazenil would not be effective in treating the respiratory depression caused by magnesium sulfate. Using flumazenil in this context would not be appropriate and could potentially lead to adverse effects.

Choice D rationale

Protamine sulfate. Protamine sulfate is not the correct choice in this scenario. Protamine sulfate is an antidote for heparin overdose, not for magnesium sulfate toxicity. It works by neutralizing the effects of heparin and preventing further anticoagulation. Since the client's issue is respiratory depression caused by magnesium sulfate, administering protamine sulfate would not be helpful and would not address the primary problem.

A. Vitamin K decreases the newborn's risk of jaundice. B. Vitamin K decreases the newborn's risk of health care-associated infections. C. Vitamin K decreases the newborn's risk of hemorrhagic disorders. D. Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine.

Correct Answer is C

Explanation

Choice A rationale :

Vitamin K decreases the newborn's risk of jaundice. Rationale: This statement is incorrect. Vitamin K plays no direct role in reducing the risk of jaundice in newborns. Jaundice is primarily caused by the accumulation of bilirubin in the blood, which is a different issue than hemorrhagic disorders.

Choice B rationale

Vitamin K decreases the newborn's risk of healthcare-associated infections. Rationale: This statement is incorrect. Vitamin K is not related to reducing the risk of healthcare-associated infections. Its main function is related to blood clotting and preventing hemorrhagic disorders.

Choice C rationale

Vitamin K decreases the newborn's risk of hemorrhagic disorders. Rationale: This statement is correct. Vitamin K is essential for the production of clotting factors in the blood, which helps prevent bleeding or hemorrhagic disorders in newborns. Newborns are born with low levels of vitamin K, so administering a vitamin K injection at birth is a common practice to prevent potential bleeding issues.

Choice D rationale

Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine. Rationale: This statement is incorrect. Vitamin K is not directly related to reducing the risk of complications from the Hepatitis B vaccine. The vaccine is designed to protect against Hepatitis B infection, and vitamin K is not involved in its efficacy or safety.

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A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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