The newborn intensive care unit (NICU) nurse receives a call to prepare for an urgent admission of a 41-week gestation newborn with appearance, pulse, grimace, activity, and respiration (APGAR) scores of 1 and 4. In preparing for the admission, what should be the nurse's highest priority?
Place the identification ankle bands at the bedside.
Set up an intravenous line with 10
Connect the resuscitation bag and mask to the oxygen outlet.
Prepare the Vitamin K injection and erythromycin ointment.
The Correct Answer is C
Neonatal resuscitation focuses on the transition to extrauterine life, emphasizing the ABCs. Nurses must apply knowledge of the Neonatal Resuscitation Program guidelines for a severely depressed infant. Prioritizing airway and ventilation is crucial for improving low Apgar scores.
Choice A rationale
Identification is a legal requirement for infant safety and security. However, in a resuscitation scenario with an Apgar score of 1, life-saving interventions like ventilation take immediate priority over administrative tasks such as applying identification bands.
Choice B rationale
Intravenous access allows for fluid volume expansion or medication delivery. While important for stabilization, it is secondary to establishing effective ventilation. Ventilation is the most critical step in improving heart rate and oxygenation in neonates.
Choice C rationale
An Apgar score of 1 indicates severe distress requiring immediate resuscitation. Preparing the bag and mask ensures that positive pressure ventilation can start immediately upon arrival. Establishing an airway and providing oxygen are the highest priorities.
Choice D rationale
Vitamin K and erythromycin are standard prophylactic treatments for newborns. These prevent bleeding and ophthalmia neonatorum, respectively. However, they are not urgent and should only be administered once the newborn is physiologically stable after resuscitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Management of labor induction requires continuous physiological monitoring to ensure maternal and fetal safety. Nurses must apply knowledge of uterine tachysystole and fetal oxygenation to prevent hypoxic injury. Establishing baseline data for uterine activity and fetal heart patterns is the primary prerequisite.
Choice A rationale
Administering large fluid boluses is not standard prior to oxytocin unless anesthesia is imminent. While hydration is important, preventing hypotension is more relevant to regional blocks than to the initiation of synthetic oxytocin for uterine contractions.
Choice B rationale
Patient education is a vital component of informed consent and nursing care. However, in an acute clinical setting, ensuring physiological safety through monitoring takes precedence over documentation of teaching before the medication is physically started.
Choice C rationale
Vertex cephalic presentation is the ideal longitudinal lie for vaginal delivery. Notifying the provider of malposition would be inaccurate as the fetus is correctly positioned. Holding the medication based on this assessment would be clinically inappropriate.
Choice D rationale
Oxytocin carries a high risk for uterine hyperstimulation. Continuous electronic fetal monitoring is essential to establish a baseline fetal heart rate and evaluate contraction frequency, ensuring the fetus tolerates the induced stress of labor contractions.
Correct Answer is A
Explanation
The scenario requires application of public health education and adolescent communication principles. Knowledge of asymptomatic sexually transmitted infections and barrier methods is essential to address the client resistance while maintaining a therapeutic relationship and promoting preventative health screenings in a non-judgmental manner.
Choice A rationale
Many infections, particularly chlamydia and gonorrhea, are asymptomatic in females. Without screening, these can lead to pelvic inflammatory disease or infertility. Education on silent transmission is the primary evidence-based method to encourage diagnostic compliance in sexually active populations.
Choice B rationale
Monogamy reduces but does not eliminate risk if the partner has an undiagnosed infection. This statement provides a false sense of security and ignores the reality of previous exposure or partner infidelity, violating basic health promotion standards.
Choice C rationale
This response is judgmental and shaming, which destroys the nurse-client relationship. Discussing abstinence after a client is already sexually active is non-therapeutic and fails to address the immediate clinical need for screening and risk reduction.
Choice D rationale
Linking infection risk strictly to race or background is discriminatory and lacks clinical nuance. While health disparities exist, stereotyping the client based on demographics is unprofessional and fails to address the individual biological risk factors of sexual activity.
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