A nurse is caring for a newborn immediately following delivery. Which of the following actions should be the nurse's priority in the resuscitation of this neonate?
Administer phytonadione IM and erythromycin in both eyes
Document the Apgar score.
Apply identification bands.
Dry and stimulate the newborn: position and open the airway, clear secretions if necessary
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Copious vaginal bleeding is not a typical sign of ectopic pregnancy. It may occur in some cases, but it is more likely to indicate a miscarriage, placenta previa, or placental abruption.
Choice B: Pelvic pain is the most common symptom of ectopic pregnancy. It usually occurs on one side of the lower abdomen and may be sharp, dull, or crampinG. The pain may worsen with movement or pressurE.
Choice C: Severe nausea and vomiting are not specific to ectopic pregnancy. They may occur in any pregnancy, especially in the first trimester. They may also be caused by other conditions, such as gastroenteritis, food poisoning, or appendicitis.
Choice D: Uterine enlargement greater than expected for gestational age is not a sign of ectopic pregnancy. It may indicate a multiple pregnancy, a molar pregnancy, or a large fibroiD. Ectopic pregnancy usually causes a smaller-than-normal uterus, because the embryo is not implanted in the uterine cavity.
Correct Answer is ["B","C","D","F"]
Explanation
Choice A: Go to break is not an appropriate action, as it can delay the necessary interventions and compromise the fetal well-beinG. The nurse should stay with the mother and monitor the fetal heart rate and the uterine activity continuously.
Choice B: Apply 100% non-rebreather mask is an appropriate action, as it can increase the maternal oxygenation and improve the fetal oxygen delivery. The nurse should place a mask with a reservoir bag over the mother's nose and mouth and adjust the flow rate to 10 to 15 L/min.
Choice C: Give an IV fluid bolus is an appropriate action, as it can increase the maternal blood volume and improve the uterine perfusion. The nurse should administer 500 to 1000 mL of isotonic crystalloid solution rapidly through a large-bore IV catheter.
Choice D: Reposition the mother is an appropriate action, as it can relieve the uterine or cord compression and improve the fetal circulation. The nurse should turn the mother to the left or right lateral position or place her in a knee-chest position.
Choice E: Increase the oxytocin drip is not an appropriate action, as it can increase the uterine contractions and reduce the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
Choice F: Decrease or stop the oxytocin is an appropriate action, as it can decrease the uterine contractions and increase the uterine relaxation and blood flow. The nurse should decrease or stop the oxytocin infusion if it is causing tachysystole or hyperstimulation.
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