Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?
Maintaining the infants’ airways.
Keeping the infants in a warm, draft-free environment.
Placing identification bands on the infants.
Monitoring the infants’ vital signs.
The Correct Answer is A
The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery. This is because twins are more likely to be born early and need special care after birth than single babies. They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.
The nurse should assess the infants’ respiratory status and intervene as needed.
Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well. Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.
Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.
The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.
Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.
The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic
• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
• Blood sugar: 40 to 80 mg/dL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This means that the uterus is constantly contracted and does not relax between contractions.This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae.Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.
Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.
Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.
Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby.Placental abruption can cause fetal distress and a decrease in fetal heart rate.
Correct Answer is C
Explanation
The correct answer is choice C. Swaddle the newborn in a flexed position.This helps to reduce the symptoms of neonatal abstinence syndrome, which is what happens when babies are exposed to drugs in the womb before birth and go through drug withdrawal after birth.Swaddling can provide comfort, warmth, and security to the newborn and decrease their stress response.
Choice A is wrong because maintaining the newborn in a reverse Trendelenburg position does not help with drug withdrawal symptoms and may increase the risk of aspiration or reflux.
Choice B is wrong because gently stroking the newborn’s face and head may overstimulate the newborn and worsen their irritability and tremors.
Choice D is wrong because providing the newborn with visual stimulation may also overstimulate the newborn and increase their discomfort and agitation.
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