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
Poor appetite can be a symptom of many neonatal conditions, but it's not the most common complication specifically associated with cephalhematoma.
Choice B rationale
Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.
Choice C rationale
Hypoglycemia is a potential concern in neonates but is not directly related to cephalhematoma.
Choice D rationale
While brain damage is a serious potential complication in cases of severe skull trauma, it's not typically associated with cephalhematoma alone. Cephalhematomas usually resolve on their own without long-term consequences.
Correct Answer is D
Explanation
Choice A rationale
While it’s true that AFP results can sometimes be false readings, it’s not the most appropriate advice for the nurse to give in this situation. Simply reassuring the client without suggesting further investigation could potentially overlook a serious condition.
Choice B rationale
Discussing options for intrauterine surgical correction of congenital defects at this stage is premature. The elevated AFP level alone does not confirm the presence of congenital defects, and suggesting surgical intervention may cause unnecessary anxiety.
Choice C rationale
Informing the client that a repeat AFP test should be conducted is a reasonable suggestion. However, it’s not the most appropriate next step in this case. A repeat test would provide more information, but it wouldn’t give definitive results about the cause of the elevated AFP level.
Choice D rationale
Explaining that a sonogram should be scheduled for definitive results is the most appropriate advice. An ultrasound can provide a more detailed view of the fetus and help identify any potential issues that might have led to the elevated AFP level. This would be the most informative next step and would guide further actions based on the findings.
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