A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Place an identification bracelet.

Dry the skin.

Administer vitamin K.

Administer eye prophylaxis.

Answer and Explanation

The Correct Answer is B

A.   Placing an identification bracelet is important but not the immediate priority after ensuring a patent airway.
B.   Drying the skin is a priority to prevent heat loss and promote thermoregulation in the newborn.
C. Administering vitamin K is important but can be done after drying the skin.
D.   Administering eye prophylaxis is important but can be done after drying the skin.

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Correct Answer is C

Explanation

A. Turning the newborn on his side may be done after suctioning but is not the initial priority.
B. Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C.Suctioning the mouth is a necessary step to ensure effective breathing.
D. Suctioningthe nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.

A. Assess the client’s uterine fundus. B. Assist the client on a bedpan to urinate. C. Increase the client’s fluid intake. D. Prepare to administer oxytocic medication.

Correct Answer is A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

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A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

Correct Answer is C

Explanation

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Correct Answer is A

Explanation

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