A nurse is caring for a client who just delivered a newborn.
Following the delivery, which nursing action should be done first to care for the newborn?

Dry the infant off and cover the head

Stimulate the infant to cry

Clear the respiratory tract

Cut the umbilical cord

Answer and Explanation

The Correct Answer is C

Choice A rationale

Drying the infant off and covering the head is important to prevent heat loss, but it is not the first action to be taken. The newborn’s body temperature can drop rapidly because of the evaporation of amniotic fluid, so drying the infant is a priority, but not the first one.

Choice B rationale

Stimulating the infant to cry is important as it helps to clear the lungs of amniotic fluid and promotes the expansion of the lungs for effective oxygenation. However, this is not the first action to be taken. The first action is to clear the respiratory tract.

Choice C rationale

Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly. This is done by suctioning the mouth first and then the nose to prevent aspiration of mucus or amniotic fluid, which can lead to respiratory distress.

Choice D rationale

Cutting the umbilical cord is done after the newborn’s respiratory status is stable. It is not the first action to be taken. The umbilical cord is usually clamped and cut by the healthcare provider after it has stopped pulsating, or after the newborn has started to breathe on their own.

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Correct Answer is C

Explanation

Choice A rationale

Betamethasone does not increase the fetal heart rate. It is a corticosteroid given to pregnant women who are at risk of preterm delivery to enhance fetal lung maturity and prevent respiratory distress syndrome.

Choice B rationale

Betamethasone is not used to stop preterm labor contractions. Other medications, such as tocolytics, are used for this purpose.

Choice C rationale

This is the correct answer. Betamethasone is given to promote fetal lung maturity. It is usually given in two doses, 24 hours apart, and takes effect within 24 hours of administration.

Choice D rationale

Betamethasone does not halt cervical dilation. It is given to enhance fetal lung maturity, not to stop labor.

A. Perineal pad clots B. Pelvic pain C. Boggy uterus D. Breast Engorgement

Correct Answer is C

Explanation

Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.

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A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. Which of the following explanations should the nurse provide?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a patient who is 36 hours postpartum. Exhibits After reviewing the information in the patient’s medical record, which of the following complications pose a greater risk for the patient?

Correct Answer is C

Explanation

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn’s plan of care?

A nurse is caring for a patient who experienced a vaginal birth 3 hours ago. Upon palpation, the fundus is displaced to the right of the midline, is firm, and is two fingerbreadths above the umbilicus. What actions should the nurse complete at this time?

A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

A nurse is caring for a client who gave birth 2 hours ago. The nurse notes that the client’s blood pressure is 60/50 mm Hg. What should be the nurse’s first action?

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client’s amniotic membranes are intact. The client suddenly states that she needs to push. What action should the nurse take?

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A nurse is caring for a client who just delivered a newborn.
Following the delivery, which nursing action should be done first to care for the newborn?