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 ["2.3"]
Explanation
Step 1 is to convert the child's weight from pounds to kilograms. 16 pounds ÷ 2.2 = 7.3 kg.
Step 2 is to calculate the total daily dose in mg. 25 mg/kg × 7.3 kg = 182.5 mg.
Step 3 is to determine the dose per administration, divided by 2 since the dose is given every 12 hours. 182.5 mg ÷ 2 = 91.25 mg.
Step 4 is to convert the dose from mg to mL using the concentration of the medication. 91.25 mg ÷ (200 mg/5 mL) = 91.25 ÷ 40 = 2.3 mL per dose. The answer is 2.3 mL.
Correct Answer is D
Explanation
Choice A rationale
An audible murmur in a neonate with a ventricular septal defect (VSD) is a common finding and does not typically require immediate intervention. While it indicates a cardiac anomaly, it is not an emergency.
Choice B rationale
Fatigue after feedings in a neonate with patent ductus arteriosus (PDA) is a sign of increased cardiac workload, but it does not indicate an immediate life-threatening situation. It requires monitoring but not urgent intervention.
Choice C rationale
Elevated blood pressure in the upper extremity in a neonate with coarctation of the aorta is a concerning finding that indicates a narrowing of the aorta. While it requires prompt evaluation and management, it may not be as immediately critical as a hypercyanotic spell.
Choice D rationale
A neonate with Tetralogy of Fallot (TOF) experiencing hypercyanotic (Tet) spells and crying indicates a severe decrease in oxygenation and is an emergency. This condition requires immediate intervention to improve oxygenation and prevent complications such as brain damage or death. .
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