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.
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Correct Answer is B
Explanation
Physiologic jaundice is a common condition in newborns that occurs when the baby’s blood contains an excess of bilirubin, a yellow pigment produced during the normal breakdown of red blood cells.In the womb, the mother’s liver removes bilirubin for the baby, but after birth the baby’s own liver must take over this function.Because the baby has more red blood cells than an adult and their liver is still immature, they may not be able to process all the bilirubin and it may build up in their skin and eyes, causing a yellowish appearance.
Choice A is wrong because it is not an increase in neonatal metabolism that causes physiologic jaundice, but rather a decrease in hepatic metabolism of bilirubin.
Choice C is wrong because it describes a different type of jaundice called hemolytic jaundice, which occurs when there is an incompatibility between the blood types of the mother and the baby, leading to an immune reaction that destroys the baby’s red blood cells faster than they can be replaced.
Choice D is wrong because it confuses the reticuloendothelial system with the hepatic system.
The reticuloendothelial system is a network of cells and tissues that are involved in immune responses and phagocytosis (the ingestion of foreign particles or cells).
The hepatic system is the system of organs and structures that are involved in liver functions, such as bile production and detoxification.
Normal ranges for bilirubin levels in newborns are 1 to 12 mg/dL (17 to 205 micromol/L) for total bilirubin and 0.2 to 1.4 mg/dL (3 to 24 micromol/L) for direct bilirubin.
Physiologic jaundice usually peaks at 3 to 5 days after birth and resolves by 2 weeks of age.
It does not require treatment unless the bilirubin levels are very high or rising rapidly, which may indicate a more serious condition or a risk of brain damage.
Correct Answer is A
Explanation
The correct answer is choice A. “Your labor may slow down if you receive an epidural now.” An epidural is a type of regional anesthesia that blocks pain in a specific area of the body.
It can be used to reduce pain during labor and delivery.
However, an epidural can also have some side effects, such as lowering blood pressure, causing fever, and slowing down labor progress.
Therefore, it is usually recommended to wait until the cervix is at least 4 to 5 cm dilated and the contractions are strong and regular before receiving an epidural.
Choice B is wrong because there is no fixed rule about how dilated the cervix needs to be before receiving an epidural.
Some women may receive an epidural earlier or later than others, depending on their pain level, medical history, and preferences.
Choice C is wrong because catheterization is not a prerequisite for receiving an epidural.
Catheterization is the insertion of a tube into the bladder to drain urine.
It may be done after receiving an epidural because the anesthesia can affect the ability to urinate.
However, it is not required before receiving an epidural.
Choice D is wrong because the station of the baby does not determine when a woman can have an epidural.
The station of the baby refers to how far the baby has descended into the pelvis.
It is measured in relation to the ischial spines, which are bony landmarks in the pelvis.
A positive station means that the baby is below the spines, while a negative station means that the baby is above the spines.
Zero station means that the baby is at the level of the spines.
The station of the baby does not affect the administration of an epidural, as long as there are no other complications or contraindications.
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