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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?

A.

Dry the infant off and cover the head

B.

Stimulate the infant to cry

C.

Clear the respiratory tract

D.

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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Related Questions

Correct Answer is C

Explanation

Choice A rationale

Neonatal abstinence syndrome is a condition that results from withdrawal from exposure to narcotics. It is not related to the newborn’s weight.

Choice B rationale

While a yellowish skin tone may indicate jaundice, this is not directly related to the newborn’s weight. Jaundice is caused by an excess of bilirubin, a yellow-orange substance in the blood.

Choice C rationale

Newborns with low birth weight are at risk for hypoglycemia because they have less stored glycogen. They may use up their glucose stores quickly and not have enough intake to maintain their blood glucose levels.

Choice D rationale

Neonatal sepsis is a severe infection in an infant less than 28 days old. It is not directly related to the newborn’s weight but can be associated with maternal infection.

Correct Answer is C

Explanation

Hypoglycemia, or low blood sugar, is a common condition in newborns, especially those born to mothers with diabetes, those who are small for their gestational age, or those who have been stressed during birth. It’s important to monitor the newborn’s serum glucose level and report any abnormalities to the healthcare provider.

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