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 C
Explanation
The correct answer is choice C. Stretching your legs and pointing your toes toward your knee will bring relief from the leg cramps.This is because stretching can help relax the muscle and ease the spasm.
Choice A is wrong because elevating your legs may not help with leg cramps, and may actually worsen them by reducing blood flow to the muscles.
Choice B is wrong because massaging your legs may not be enough to relieve the cramps, and may also cause more pain if done too hard or too fast.
Choice D is wrong because putting a cold compress on the calf of your leg may not be effective for leg cramps, and may also cause more discomfort or inflammation.
Leg cramps are common during pregnancy, especially in the second and third trimester.They are caused by various factors, such as pregnancy weight gain, changes in blood circulation, pressure on the nerves and blood vessels, nutrient deficiency, lack of exercise, or fluid buildup in your legs.To prevent or reduce leg cramps, you should drink plenty of water, stay active, eat a balanced diet rich in calcium, magnesium, and potassium, avoid standing or sitting for long periods of time, wear comfortable shoes and socks, and sleep on your left side with a pillow under or between your legs.
If leg cramps persist or become severe, you should consult your healthcare provider for possible treatment options.
Correct Answer is C
Explanation
The correct answer is choice C: Related to the influence of maternal hormones.This is because breast milk contains many hormones that pass into it from the mother’s body, such as prolactin, thyroid hormones, and estrogen.
These hormones can affect the baby’s growth and development, and sometimes cause temporary breast enlargement and milk secretion in newborns of both sexes.This is called neonatal galactorrhea or “witch’s milk” and it is harmless and usually resolves within a few weeks
Choice A is wrong because neonatal galactorrhea is not a symptom of an endocrine disorder.It is a normal physiological response to maternal hormones that cross the placenta during pregnancy and are present in breast milk
Choice B is wrong because neonatal galactorrhea is not related to the need for chromosomal determination of gender identity.Gender identity is determined by a complex interaction of genetic, hormonal, and environmental factors, and it is not influenced by breast milk production in newborns
Choice D is wrong because neonatal galactorrhea is not a symptom of an abnormal proliferation of mammary alveoli.
Mammary alveoli are the milk-producing cells in the breast, and they are stimulated by prolactin to secrete milk.Neonatal galactorrhea does not indicate any abnormality in the structure or function of the mammary glands
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