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 reason: This is not the correct finding because it indicates a possible uterine rupture, which is a complication of placental abruption, not placenta previA. Placental abruption is the premature separation of the placenta from the uterine wall, which can cause severe pain, bleeding, and fetal distress.
Choice B reason: This is the correct finding because it indicates a possible placenta previa, which is the implantation of the placenta over or near the cervical os. Placenta previa can cause painless bleeding that increases as the cervix dilates and effaces.
Choice C reason: This is not the correct finding because it indicates a possible onset of labor, which is not a complication of placenta previA. Labor can cause contractions, bloody show, and cervical changes, but it does not cause excessive bleeding or pain.
Choice D reason: This is not the correct finding because it indicates a possible marginal placenta previa, which is a less severe form of placenta previa that does not cover the cervical os. Marginal placenta previa can cause mild bleeding and pain, but it is not as dangerous as a complete or partial placenta previA.
Correct Answer is C
Explanation
Choice A: Prolapsed cord is not a likely complication, as it is characterized by a sudden onset of severe variable decelerations of the fetal heart rate and a visible or palpable cord in the vaginA. The nurse should identify a prolapsed cord as a medical emergency and perform immediate interventions to relieve the cord compression and deliver the fetus.
Choice B: Premature rupture of membranes is not a likely complication, as it is characterized by a gush or a trickle of clear or yellowish fluid from the vagina and a positive nitrazine or fern test. The nurse should identify premature rupture of membranes as a risk factor for infection and monitor the fetal heart rate and the maternal temperaturE.
Choice C: Abruptio placentae is a likely complication, as it is characterized by continuous abdominal pain and dark red vaginal bleeding and a board-like abdomen. The nurse should identify abruptio placentae as a life-threatening condition that involves the premature separation of the placenta from the uterine wall and can cause fetal distress and maternal hemorrhagE.
Choice D: Placenta previa is not a likely complication, as it is characterized by painless bright red vaginal bleeding and a soft and relaxed uterus. The nurse should identify placenta previa as a condition that involves the abnormal implantation of the placenta near or over the cervical os and can cause fetal hypoxia and maternal hemorrhagE.
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