A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Confirm the newborn's Apgar score

Verify the newborn's identification.

Administer vitamin K to the newborn.

Determine obstetrical risk factors.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Confirming the newborn's Apgar score is important for assessing the newborn's overall condition, but it may not be the first priority.

Choice B Reason:

Verifying the newborn's identification is appropriate. Ensuring accurate identification is a crucial step in newborn care to prevent errors and ensure that interventions are carried out on the correct infant.

Choice C Reason:

Administering vitamin K is a standard practice but can wait until after the newborn's identification is confirmed.

Choice D Reason:

Determining obstetrical risk factors is part of the overall assessment but is not the immediate priority in this situation.

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Correct Answer is A

Explanation

a.Panting helps to control the urge to push and can slow down the delivery, which is important to prevent rapid delivery that could cause injury to both the mother and the baby. It allows the nurse or healthcare provider to better manage the delivery process.

b.Slow-paced breathing is often used during early labor to help manage pain and anxiety. However, when the baby’s head is crowning, panting is more effective in controlling the urge to push and slowing down the delivery process.

c.While deep cleansing breaths can be helpful during contractions to manage pain and focus, they are not as effective as panting in controlling the urge to push during the crowning phase.

d.While it might seem natural to encourage pushing when the baby’s head is crowning, it’s important to control the delivery to prevent rapid birth, which can cause injury to both the mother and the baby. Encouraging the mother to pant helps slow down the process, allowing for a more controlled and safer delivery.

A. Help the client to the bathroom to void B. Observe the perineum for signs of crowning C. Have the client pant during the next contractions D. Assist the client into a comfortable position

Correct Answer is C

Explanation

A. Helping the client to the bathroom to void is not the priority in this situation. The urge to push could indicate that the baby is descending, and the nurse should be prepared for imminent delivery.

B. Observing the perineum for signs of crowning is a valid action, but having the client pant during contractions is more appropriate at this stage. It can help prevent rapid descent and potential trauma if delivery is imminent.

C. Having the client pant during the next contractions is the correct action.

Panting during contractions may slow down the urge to push and prevent rapid delivery, especially if the healthcare provider is not present or the delivery is not imminent.

D. Assisting the client into a comfortable position is important, but the priority is to manage the urge to push. Panting can be an effective technique for delaying pushing until the healthcare provider is ready for the delivery.

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A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make to the client?

Correct Answer is A

Explanation

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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