A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority?
Dry the newborn.
Administer phytonadione IM.
Document the Apgar score.
Apply identification bands.
The Correct Answer is A
Choice A reason:
Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.
Choice B reason:
Administering phytonadione IM is not the nurse's priority because it is not an immediate life-saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.
Choice C reason:
Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.
Choice D reason:
Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Asymmetrical breathing is not a sign of meconium aspiration syndrome (MAS). It is a sign of diaphragmatic hernia, a condition where the abdominal organs push into the chest cavity and interfere with lung development.
Choice B reason:
Born before 38 weeks gestation is not a sign of MAS. It is a risk factor for respiratory distress syndrome (RDS), a condition where the lungs are not fully developed and lack surfactant, a substance that helps keep the air sacs open.
Choice C reason:
Yellow-green staining on the umbilical cord is a sign of MAS. It indicates that the baby has passed meconium into the amniotic fluid before or during birth and may have inhaled it into the lungs. Meconium is a sticky substance that becomes the baby's first poop. It can block or irritate the airways, damage lung tissue and prevent oxygen exchange.
Choice D reason:
Acrocyanosis is not a sign of MAS. It is a normal finding in newborns where the hands and feet appear bluish due to immature circulation. It usually resolves within 24 to 48 hours after birth.
Correct Answer is A
Explanation
Choice A reason:
Placental insufficiency is a condition in which the placenta does not deliver enough oxygen and nutrients to the developing baby, resulting in restricted growth and development. This is one of the most common causes of SGA babies.
Choice B reason:
Primipara means a woman who is pregnant for the first time or who has given birth to one child. Primipara is not a cause of SGA, although some studies have suggested that first-time mothers may have a slightly higher risk of having a low-birth-weight baby than multiparous women.
Choice C reason:
Maternal obesity is a condition in which the mother has a body mass index (BMI) of 30 or higher before or during pregnancy. Maternal obesity is not a cause of SGA, but rather a risk factor for having a large-for-gestational-age (LGA) baby, which can lead to complications such as macrosomia, shoulder dystocia, and birth trauma.
Choice D reason:
Perinatal asphyxia is a condition in which the baby does not receive enough oxygen before, during, or after birth, causing hypoxia and acidosis. Perinatal asphyxia is not a cause of SGA, but rather a possible complication of SGA, especially if the placental insufficiency is severe or prolonged. Perinatal asphyxia can damage the brain and other organs of the baby and lead to long-term neurological impairments.
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