A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse’s priority action?
Administer Vitamin K
Administer eye prophylaxis
Place an identification bracelet
Dry the skin
The Correct Answer is D
Choice A rationale
Administering Vitamin K is an important step in newborn care as it helps with blood clotting and prevents a rare but serious bleeding disorder called Vitamin K Deficiency Bleeding.
However, it is not the immediate priority after ensuring a patent airway.
Choice B rationale
Administering eye prophylaxis, typically in the form of antibiotic ointment, is a standard procedure in newborn care to prevent neonatal conjunctivitis. However, this is not the immediate priority after ensuring a patent airway.
Choice C rationale
Placing an identification bracelet on the newborn is crucial for ensuring the baby’s safety and preventing mix-ups. However, this is not the immediate priority after ensuring a patent airway.
Choice D rationale
Drying the skin of the newborn is the priority action after ensuring a patent airway. This is because newborns are wet with amniotic fluid at birth, and they can lose heat quickly through evaporation if not dried immediately. This can lead to hypothermia, which can be dangerous for the newborn.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Intermittent abdominal pain following the passage of bloody mucus can be a sign of labor or other complications, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice B rationale
Painless red vaginal bleeding is a classic symptom of placenta previa. This occurs because the placenta is covering part or all of the cervix, leading to bleeding as the cervix begins to thin and open in preparation for labor.
Choice C rationale
Abdominal pain with scant red vaginal bleeding could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Choice D rationale
Increasing abdominal pain with a non-relaxed uterus could indicate various conditions, but it is not a typical finding that supports the diagnosis of placenta previa.
Correct Answer is A
Explanation
Choice A rationale
Applying lotion to the newborn’s skin during phototherapy is not recommended. Lotion can block the light from reaching the skin and reduce the effectiveness of the treatment.
Choice B rationale
Covering the newborn’s eyes with a mask during phototherapy is a standard practice. This is done to protect the newborn’s eyes from the intense light used in phototherapy.
Choice C rationale
An increase in stool frequency is expected during phototherapy. This is because phototherapy helps to break down bilirubin, which is then excreted in the stool.
Choice D rationale
A pink rash on the newborn’s trunk does not require intervention during phototherapy. It could be a common newborn rash that will resolve on its own.
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