The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What priority issue should the nurse address to ensure the newborn’s survival?
Heat loss.
Hypoglycemia.
Fluid balance.
Bleeding tendencies.
The Correct Answer is A
Choice A rationale
Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss.
Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.
Choice B rationale
While hypoglycemia is a concern in newborns, especially those born to mothers with diabetes, it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
Choice C rationale
Fluid balance is important in newborns, but it is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
Choice D rationale
While newborns do have immature clotting mechanisms, making them more prone to bleeding tendencies, this is not the immediate priority in this scenario. The first step in stabilizing a newborn after birth is to ensure adequate respirations and prevent heat loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
Choice B rationale
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
Choice C rationale
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
Choice D rationale
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
Correct Answer is B
Explanation
Choice A rationale
Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.
Choice B rationale
Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.
Choice C rationale
While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.
Choice D rationale
The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.
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