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 ["B","C"]
Explanation
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Correct Answer is B
Explanation
Choice A rationale
Oxytocin is not involved in returning the uterus to its prepregnancy size. Instead, it helps in uterine contractions, which facilitate the expulsion of the placenta and reduce postpartum bleeding. The process of uterine involution, returning to prepregnancy size, is primarily managed by the natural decline of pregnancy hormones and autolysis of uterine tissue.
Choice B rationale
Oxytocin stimulates uterine contractions, which is its primary function during labor and after delivery. These contractions help deliver the baby during labor and facilitate the expulsion of the placenta. After delivery, oxytocin continues to induce contractions to minimize postpartum hemorrhage and aid uterine involution.
Choice C rationale
Oxytocin can activate the let-down reflex for breastfeeding, but it is not the primary expected outcome when administered IV after delivery. The main goal post-delivery is to manage uterine contractions to prevent hemorrhage and assist in expelling the placenta.
Choice D rationale
While oxytocin assists in expelling the placenta by stimulating contractions, this is not its primary use post-delivery. The placenta typically detaches and is delivered shortly after birth. Oxytocin's main role after delivery is to continue stimulating contractions to reduce bleeding and help the uterus return to a non-pregnant state.
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