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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Related Questions
Correct Answer is A
Explanation
Choice A reason:
Eating leafy green vegetables is a good way to increase iron intake, as they are rich in iron and other nutrients. Iron is needed to produce hemoglobin, the protein that carries oxygen in red blood cells. Iron deficiency anemia occurs when there is not enough iron to make hemoglobin, resulting in low red blood cell count and low oxygen delivery to the tissues.
Leafy green vegetables such as broccoli, kale, turnip greens, and collard greens are among the best sources of iron from plants.
Choice B reason:
Taking calcium supplements is not helpful for iron deficiency anemia, as calcium can interfere with iron absorption. Calcium binds to iron in the intestine and prevents it from being absorbed into the bloodstream. Therefore, calcium supplements should not be taken at the same time as iron supplements or iron-rich foods. Calcium is important for bone health, but it does not affect hemoglobin production or red blood cell count.
Choice C reason:
Consuming two glasses of prune juice daily is not advisable for iron deficiency anemia, as prune juice has a laxative effect and can cause diarrhea. Diarrhea can lead to dehydration and loss of nutrients, including iron. Prune juice also contains oxalates, which are compounds that can reduce iron absorption by forming insoluble complexes with iron in the intestine. Prune juice does contain some iron, but not enough to compensate for its negative effects on iron status.
Choice D reason:
Consuming raw sushi is not recommended for iron deficiency anemia, as raw fish can contain parasites or bacteria that can cause infections. Infections can increase inflammation and blood loss, which can worsen iron deficiency anemia. Raw fish also contains phytates, which are substances that can inhibit iron absorption by binding to iron in the intestine. Raw fish does provide some iron, but it is not a reliable or safe source of iron for people with iron deficiency anemia. : Iron deficiency anemia - Diagnosis & treatment - Mayo Clinic. : Iron- Deficiency Anemia - Hematology.org.
Correct Answer is ["B","F","G"]
Explanation
Choice A reason:
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure is usually normal or slightly elevated in NAS, and it is not a reliable indicator of the severity of withdrawal symptoms.
Choice B reason:
Gastrointestinal disturbances are a common and serious finding for a newborn with NAS. Vomiting and diarrhea can lead to dehydration, electrolyte imbalance, and poor weight gain. Projectile vomiting can also increase the risk of aspiration. This finding requires immediate follow-up and intervention.
Choice C reason:
Skin color is not a priority finding for a newborn with NAS. Acrocyanosis (bluish color of the hands and feet) is a normal finding in newborns and does not indicate hypoxia or poor circulation. It usually resolves within the first few days of life.
Choice D reason:
NAS score is not a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. It is based on a set of clinical signs and symptoms that are scored at regular intervals. However, it is not a substitute for clinical judgment and individualized care. The NAS score alone does not determine the urgency of follow-up.
Choice E reason:
Temperature is not a priority finding for a newborn with NAS. The temperature may be slightly elevated or normal in NAS, and it is not a specific sign of infection or withdrawal. Temperature regulation is important for newborns, but it is not an immediate concern in this case.
Choice F reason:
Oxygen saturation is a priority finding for a newborn with NAS. Tachypnea (rapid breathing) and retractions (inward movement of the chest wall) are signs of respiratory distress, which can compromise oxygen delivery to the tissues and organs. Hypoxia (low oxygen level) can cause brain damage, organ failure, and death if not corrected promptly. This finding requires immediate follow-up and intervention.
Choice G reason:
Central nervous system disturbances are a priority finding for a newborn with NAS. Increased muscle tone, tremors, high-pitched cries, and seizures are signs of neurological dysfunction, which can indicate brain injury, bleeding, or infection. Seizures can also worsen hypoxia and metabolic acidosis. This finding requires immediate follow-up and intervention.
Choice H reason:
Respiratory rate is not a priority finding for a newborn with NAS. Respiratory rate may be increased or normal in NAS, and it is not a specific sign of respiratory distress or infection. Respiratory rate should be monitored along with other vital signs, but.
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