A practical nurse (PN) who works in the nursery is attending the vaginal delivery of a term infant. Which action should the PN complete prior to transporting the baby to the nursery?
Obtain the infant's vital signs.
Administer vitamin K injection.
Place the ID bands on the infant and mother.
Observe the infant latching onto the breast.
The Correct Answer is C
The correct answer is Choice C. Place the ID bands on the infant and mother.
Choice A rationale:
While obtaining the infant's vital signs is important, it is not the priority action before transporting the baby to the nursery. Placing ID bands on the infant and mother ensures proper identification and prevents mix-ups during transportation, which is crucial in the nursery setting.
Choice B rationale:
Administering vitamin K injection is also essential but not the immediate priority before transporting the baby. Vitamin K administration helps prevent bleeding disorders in newborns, but ensuring proper identification and security come first.
Choice C rationale:
The correct choice. Placing ID bands on the infant and mother is the most important action before transporting the baby to the nursery. This step ensures accurate identification and matching between the baby and the mother, preventing any confusion or errors in the hospital setting.
Choice D rationale:
Observing the infant latching onto the breast is important for promoting breastfeeding, but it can be done after ensuring proper identification and safety measures have been taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer isChoice B.
Choice B rationale:
The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.
Choice A rationale:
Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.
Choice C rationale:
Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.
Choice D rationale:
Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.
Correct Answer is A
Explanation
This is the best action for the PN to implement because it addresses the client's question and provides an opportunity to educate the client about fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will affect the client's elimination and body image.
B. Verifying that the client had nothing by mouth (NPO) for the past 24 hours is not relevant to the client's question and does not provide any information or support.
C. Asking the client if he finished the bowel sterilization prescription is not relevant to the client's question and does not provide any information or support.
D. Determining if this is the first indwelling catheter the client has had is not relevant to the client's question and does not provide any information or support.
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