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

The correct answer is A. Two arteries and one vein.

A. Two arteries and one vein is the typical composition of the umbilical cord vessels. The umbilical arteries carry deoxygenated blood and waste products away from the fetus, while the umbilical vein carries oxygenated blood and nutrients to the fetus.

B. Two veins and one artery is not the usual configuration of the umbilical cord vessels. The presence of two veins is atypical.

C. One artery and one vein is an abnormal finding and may be associated with certain congenital anomalies or fetal abnormalities. This configuration is not the norm.

D. Two arteries and two veins is not a standard or physiological composition of the umbilical cord. The typical configuration is two arteries and one vein.

A. Monitor the fetal heart rate (FHR) every hour B. Insert an indwelling urinary catheter. C. Keep four side rails up while the client is in bed D. Check the cervix prior to analgesic administration

Correct Answer is A

Explanation

The correct answer is A. Monitor the fetal heart rate (FHR) every hour.

A. Monitoring the fetal heart rate every hour is a crucial aspect of the plan of care during active labor. Continuous fetal monitoring helps assess the well-being of the baby and ensures timely identification of any signs of fetal distress.

B. Inserting an indwelling urinary catheter is not a routine intervention during active labor. The bladder can be monitored using other non-invasive methods, and catheterization is generally reserved for specific indications.

C. Keeping four side rails up while the client is in bed is not recommended. It may limit the client's mobility and is not a standard practice during labor. Ensuring the safety of the client and promoting mobility is important.

D. Checking the cervix prior to analgesic administration may be necessary, but it is not a general action for every client in active labor. The need for cervical checks should be individualized based on the client's progress, preferences, and clinical indications.

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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

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