The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
Which priority issue should the nurse address to ensure the newborn's survival?
Bleeding tendencies.
Fluid balance.
Heat loss.
Hypoglycemia.
The Correct Answer is C
Choice A rationale
While bleeding tendencies can be a concern in newborns, especially if there are clotting disorders, it is not the immediate priority in the first minutes after birth. Immediate interventions focus on establishing effective respirations and ensuring adequate oxygenation.
Choice B rationale
Fluid balance is important for newborns, particularly in the context of hydration and potential complications like hypovolemia. However, the most immediate concern after birth is ensuring the newborn can breathe adequately to deliver oxygen to the body's tissues.
Choice C rationale
Heat loss is a critical issue for newborns, as they are at high risk for hypothermia due to their large surface area relative to body weight and limited ability to generate heat. Preventing heat loss helps to stabilize the newborn's temperature and supports overall physiological stability, including respiratory function.
Choice D rationale
Hypoglycemia can be a concern in newborns, particularly those who are small for gestational age or have other risk factors. However, the most immediate concern in the first minutes after birth is ensuring adequate breathing to support oxygenation and prevent complications related to hypoxia. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Reduction of fever is not the primary goal of albumin therapy. Albumin's role in nephrotic syndrome is to manage severe edema, not to reduce fever, which might be managed by antipyretics if present.
Choice B rationale
Weight gain is typically undesirable in nephrotic syndrome patients due to fluid retention and edema. Albumin therapy aims to reduce edema, potentially decreasing weight as fluid balance improves.
Choice C rationale
Albumin infusion helps reduce edema by increasing plasma oncotic pressure, drawing fluid back into the vascular system. A reduction in edema indicates the therapy’s effectiveness in managing nephrotic syndrome symptoms.
Choice D rationale
Improved caloric intake is not directly affected by albumin infusion. While managing edema might improve overall well-being, albumin’s primary function in this context is fluid balance and reducing swelling.
Correct Answer is D
Explanation
Choice A rationale
This choice suggests assessing if the child can administer the insulin. While it's important for children with diabetes to learn self-care skills, a 10-year-old may not yet be ready to take on the responsibility of injecting insulin regularly. The child might still rely on parental or caregiver support for this task. Moreover, it does not address the immediate issue of the mother's fear of needles.
Choice B rationale
This choice focuses on assessing the mother's parenting skills. It is not directly related to solving the issue of insulin administration. The mother's fear of needles does not necessarily reflect her overall parenting skills. Assessing parenting skills would not provide a practical solution to the child's need for insulin administration.
Choice C rationale
Encouraging the mother to handle the needles could help overcome her fear, but it might not be effective in the short term. The mother might need time and professional help to deal with her fear of needles. This choice does not provide an immediate solution for the child's need for insulin injections.
Choice D rationale
Asking if the father can help with the injections is a practical and immediate solution. If the father is available and comfortable with handling needles, he can take on the responsibility of administering insulin to the child. This ensures that the child's medical needs are met while giving the mother time to overcome her fear of needles.
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