A nurse is caring for a newborn immediately following birth.
After establishing a patent airway, what is the next priority nursing action?
Administer vitamin K.
Dry and stimulate the newborn.
Administer eye prophylaxis.
Place an identification bracelet on the newborn and mother.
The Correct Answer is B
Choice A rationale
Administering vitamin K (phytonadione) is routinely done to prevent hemorrhagic disease of the newborn, as infants have sterile guts and lack the necessary bacteria to synthesize clotting factors II, VII, IX, and X. While important, this intervention is a prophylactic chemical measure and is performed after the critical initial physiological stabilization steps, making it secondary to maintaining thermal stability.
Choice B rationale
Drying the newborn immediately and thoroughly stimulates breathing, reduces evaporative heat loss, and is critical for stabilizing the newborn's temperature and preventing cold stress. Maintaining a neutral thermal environment is the next priority after ensuring a patent airway, as hypothermia can lead to serious complications like metabolic acidosis and hypoglycemia.
Choice C rationale
Administering eye prophylaxis, typically erythromycin ointment, is a legally mandated procedure to prevent ophthalmia neonatorum from pathogens like Neisseria gonorrhoeae. This is an important preventive measure but is not a critical physiological stabilization step and can be performed after the initial steps of airway, breathing, and circulation stabilization are complete.
Choice D rationale
Placing identification bracelets on the newborn and mother is a vital safety and security measure to prevent infant abduction or mix-ups. This is a crucial procedural task but does not address the immediate, life-sustaining physiological needs of the newborn, such as maintaining respiration and thermoregulation, making it a lower priority than drying and stimulating the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
False labor contractions, often called Braxton Hicks, are typically irregular and weak, do not increase in intensity or duration over time, and usually cease with walking or changing position. Importantly, false labor does not cause progressive changes in the cervix, meaning the dilation would not progress from 4 cm to 6 cm as described in this clinical scenario. This lack of cervical change differentiates it from true labor.
Choice B rationale
Placental abruption involves the premature separation of the placenta from the uterine wall, which usually presents with painful, firm, or rigid uterine tone and often vaginal bleeding. While the uterus is firm, the complete softening between contractions and progressive cervical change are classic signs of normal labor, not the sustained, often hypertonic, rigidity associated with a severe abruption.
Choice C rationale
Uterine tachysystole is defined as more than five contractions in a 10-minute period, averaged over 30 minutes, or a series of single contractions lasting longer than 2 minutes. The scenario describes contractions lasting 45 seconds with complete relaxation between, which is within the normal range for active true labor, and does not meet the criteria for tachysystole.
Choice D rationale
True labor is characterized by a pattern of regular, strong contractions that lead to progressive effacement and dilation of the cervix. The contractions described, which make the uterus firm, last 45 seconds, and are associated with cervical change from 4 cm to 6 cm, fit the criteria for active true labor.
Correct Answer is D
Explanation
Choice A rationale
The Moro reflex, which is a startle response involving the baby suddenly extending and then retracting their arms, is a normal neurological reflex present in newborns. It is an involuntary response to a sudden change or sound and does not indicate the infant is hungry or ready to begin the active process of feeding.
Choice B rationale
Crying is considered a late sign of hunger in a newborn, often indicating that the baby is already highly stressed and frustrated. Trying to feed an infant who is already crying often makes latching and effective feeding more difficult; therefore, earlier, calmer feeding cues should be identified and acted upon first.
Choice C rationale
Hiccups are a common, usually benign phenomenon in newborns, often caused by an immature digestive system or rapid stomach expansion. While sometimes associated with a full stomach after a feeding, hiccups are not a recognized or reliable feeding readiness cue that indicates the infant is seeking a feeding.
Choice D rationale
Hand-to-mouth motions, rooting (turning the head and opening the mouth when the cheek is stroked), and lip-smacking are all examples of early and clear feeding readiness cues, also known as signals of hunger. These behaviors indicate that the infant is alert, ready, and actively seeking food before becoming overly distressed or fatigued.
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