A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?

Instill erythromycin ophthalmic ointment in the newborn's eyes.

Weigh the newborn.

Place identification bracelets on the newborn.

Dry the newborn.

Answer and Explanation

The Correct Answer is D

A. Instilling erythromycin ophthalmic ointment in the newborn's eyes is important to prevent neonatal conjunctivitis, but drying the newborn takes precedence to prevent heat loss and stimulate breathing immediately after birth.

B. Weighing the newborn and placing identification bracelets can be done after drying the newborn.

C. Placing identification bracelets on the newborn is important for identification purposes but does not take precedence over drying the newborn to prevent heat loss and stimulate breathing.

D. Dry the newborn: Drying the newborn is the priority immediately after birth to prevent heat

loss and stimulate breathing. The newborn is wet from amniotic fluid and may be cold due to the temperature difference between the intrauterine and extrauterine environment. Drying the newborn with a warm, soft towel helps to prevent hypothermia and promotes the initiation of breathing, which is essential for oxygenation and lung expansion. This action supports the

newborn's transition to extrauterine life and sets the stage for subsequent assessments and interventions.

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Correct Answer is A

Explanation

A. Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B. Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C. Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D. Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.

A. Insert an indwelling catheter if the client has not voided in 3 hr. B. Obtain the abdominal girth now and every 4 hr. C. Assess and document the level of consciousness every hour. D. Measure the amount of gastric drainage every 2 hr.

Correct Answer is A

Explanation

A. Inserting an indwelling catheter is within the scope of practice for an LPN and requires technical skill and training that an LPN possesses. This task is appropriate for delegation because it does not require the RN's direct clinical judgment or assessment at the time of insertion. The LPN can perform this procedure based on a specific directive from the RN.
B. Obtaining the abdominal girth is a task that involves assessment and this cannot be delegated by the RN to an LPN.

C. Assessing and documenting the level of consciousness involves critical thinking and

interpretation of assessment findings, making it more appropriate for the registered nurse to perform.

D. Measuring gastric drainage is a task that the LPN can perform, but it is less critical compared to the insertion of an indwelling catheter in this scenario. The RN should prioritize delegating tasks to the LPN that require their specific skills, such as catheter insertion, while reserving simpler tasks for the AP.

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A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?

Correct Answer is A

Explanation

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

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