The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?
Hypoglycemia.
Bleeding tendencies.
Heat loss.
Fluid balance.
The Correct Answer is C
Choice A rationale
Hypoglycemia, or low blood sugar, is a concern in newborns, but it is not the most immediate concern within the first minutes after delivery.
Choice B rationale
While newborns do have certain bleeding tendencies due to immature clotting mechanisms, this is not the immediate priority in the first minutes after birth.
Choice C rationale
The priority issue that the nurse should address to ensure the newborn’s survival is heat loss.
Newborns are at high risk of heat loss and maintaining their body temperature is crucial. This is because they have a large body surface area relative to their weight and their temperature regulation mechanism is not fully developed.
Choice D rationale
Fluid balance is important in newborns, but it is not the immediate concern in the first minutes after birth. The initial focus is on establishing respiration and maintaining body temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.72"]
Explanation
Step 1 is to calculate the total amount of oxytocin in the IV bag. This is done by multiplying the total volume of the bag by the concentration of oxytocin. In this case, the bag contains 5 units of oxytocin in 500 mL, so the concentration is 5 units ÷ 500 mL = 0.01 units/mL.
Step 2 is to convert the prescribed dose from milliunits/min to units/hour. There are 1000 milliunits in a unit and 60 minutes in an hour, so 12 milliunits/min = 12 ÷ 1000 units/min = 0.012 units/min. Then, 0.012 units/min × 60 min/hour = 0.72 units/hour.
Step 3 is to calculate the infusion rate in mL/hour. This is done by dividing the prescribed dose in units/hour by the concentration of oxytocin in units/mL. So, 0.72 units/hour ÷ 0.01 units/mL = 72 mL/hour. Therefore, the nurse should set the infusion pump to 72 mL/hour.
Correct Answer is A
Explanation
Choice A rationale
Monitoring the capillary refill of the toes is crucial when a child has a long-leg cast applied. This is because it helps assess the adequacy of circulation to the foot, which can be compromised by the cast. If the capillary refill is delayed (more than 2 seconds), it could indicate poor blood flow to the area, which could lead to serious complications such as tissue necrosis.
Choice B rationale
Comparing the temperature of both legs can provide information about circulation and inflammation. However, it is not the most important action in this case. While a significant difference in temperature could indicate a problem, it is not as direct an indicator of circulatory status as capillary refill.
Choice C rationale
Observing for spontaneous movement can provide information about nerve function. If the child is not moving the toes, it could indicate nerve damage. However, lack of movement could also be due to discomfort from the cast and is not as direct an indicator of circulatory status as capillary refill.
Choice D rationale
Checking the femoral pulses can provide information about circulation to the leg. However, the femoral pulse is proximal to the cast and may not accurately reflect circulation to the foot. Therefore, it is not the most important action in this case.
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