A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Stimulate the infant to cry.

Clear the respiratory tract.

Dry the infant off and cover the head.

Clamp the umbilical cord.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Stimulate the infant to cry. While stimulating the infant to cry is a common practice to assess the newborn's respiratory function, it is not the first action the nurse should perform in this situation. The newborn may cry spontaneously or may require other interventions, such as clearing the respiratory tract, before crying.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract is the priority action in this scenario. It ensures that the airway is open and allows the infant to breathe effectively. This is crucial because newborns are at higher risk of respiratory distress after birth, and prompt action can prevent complications.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head are important steps to prevent heat loss and maintain the newborn's body temperature. However, these actions can be delayed briefly until the respiratory tract is cleared, as the immediate focus should be on ensuring the infant's ability to breathe.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is a standard procedure after birth to prevent bleeding and infection. However, it is not the priority in this situation. The first step should be to ensure the newborn's airway is clear and they can breathe adequately.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

Dysuria - Dysuria refers to painful or difficult urination. In a client with a urinary tract infection (UTI), this symptom is commonly present. The rationale behind this finding is that the infection irritates the urinary tract, causing discomfort and pain during urination. The client may experience a burning sensation or pressure while passing urine.

Choice D rationale

Hematuria - Hematuria refers to the presence of blood in the urine. In the case of a UTI, inflammation of the urinary tract can lead to tiny blood vessels rupturing, resulting in blood in the urine. This can cause the urine to appear pink, red, or brownish.

Choice E rationale:

Urinary frequency - Urinary frequency is another common symptom of a UTI. The infection can irritate the bladder lining, leading to an increased urge to urinate even when the bladder is not full. The client may feel the need to urinate frequently throughout the day and night.

Choice B rationale

Dependent edema - Dependent edema is not typically associated with a urinary tract infection. Edema is the accumulation of fluid in tissues, often causing swelling in the lower extremities due to gravity (dependent). This symptom is more commonly related to issues such as heart, kidney, or liver problems.

Choice C rationale

Polyuria - Polyuria refers to excessive urination, usually producing abnormally large volumes of urine. While frequent urination is a symptom of a UTI, polyuria, in this context, is not accurate. UTIs tend to cause frequent but smaller volumes of urine due to the irritation and inflammation of the bladder.

A. Vaginal hematoma. B. Hypoglycemia. C. Chorioamnionitis. D. Uterine hemorrhage. E. Dehiscence.

Correct Answer is D

Explanation

Choice A rationale:

Vaginal hematoma is not a common complication in the 4th stage of labor. This stage primarily involves the recovery and stabilization of the mother after delivery.

Choice B rationale:

Hypoglycemia is not a typical complication in the 4th stage of labor. While blood glucose levels might be monitored during labor, the risk of hypoglycemia is generally higher in neonates, especially if the mother has diabetes.

Choice C rationale:

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, typically diagnosed during labor or shortly after delivery. It is not specific to the 4th stage of labor.

Choice D rationale:

Uterine hemorrhage is the most significant concern during the 4th stage of labor, also known as the "postpartum”. or "recovery”. stage. It refers to excessive bleeding from the site where the placenta detached. This bleeding can be life-threatening if not managed promptly.

Choice E rationale:

Dehiscence is the separation of surgical incisions, which is not a common complication during the 4th stage of labor.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

When contributing to the plan of care for the 4th stage of labor, the nurse should recognize the client is at the greatest risk of developing which of the following complications?

Correct Answer is D

Explanation

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply)

When contributing to the plan of care for the 4th stage of labor, the nurse should recognize the client is at the greatest risk of developing which of the following complications?

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply)

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

A nurse is caring for a client who is pregnant in a provider's office. Exhibits Which of the following findings should the nurse report to the provider? (Select all that apply)