Just after a client delivers a baby who weighs 7 pounds (3.18 kg), what is the priority nursing action?
Obtain a serum sample.
Dry off the newborn.
Assess the newborn’s Moro reflex.
Obtain the newborn’s footprints.
The Correct Answer is B
The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.
The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress. Drying off the newborn also stimulates breathing and crying, which helps clear the airways.
Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.
Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination. Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. “What drugs have you used during your pregnancy?”.
This question is open-ended and nonjudgmental, which encourages the patient to disclose more information about her drug use.
The nurse can then assess the type, frequency, and amount of drugs used and plan appropriate interventions.
Choice A is wrong because it is a closed-ended question that can be answered with a yes or no, and it implies criticism of the patient’s behavior, which may make her defensive and less willing to cooperate.
Choice B is wrong because it is also a closed-ended question that can be answered with a yes or no, and it may frighten or anger the patient, who may not be aware of the legal implications of her drug use.
Choice D is wrong because it is too vague and may not cover all the possible drugs that the patient may have used, such as prescription medications, alcohol, or tobacco.
It also labels the patient as a drug user, which may offend her or make her feel ashamed.
Correct Answer is D
Explanation
This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.
The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.
Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia.Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.
However, this is not related to epidural anesthesia.
Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia.Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).
However, this is not related to epidural anesthesia.
Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.
Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects.It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.
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