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.

Answer and Explanation

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

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Correct Answer is D

Explanation

The correct answer is choice D: To prevent her from having convulsions.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy.Magnesium sulfate can lower the cerebral perfusion pressure and prevent convulsions.However, magnesium sulfate does not affect the neonatal outcomes and can cause side effects such as respiratory depression.

Choice A is wrong because magnesium sulfate does not decrease blood pressure.It is used along with medications that help reduce blood pressure.

Choice B is wrong because magnesium sulfate does not decrease tidal volume.It can cause respiratory depression if the serum level is too high.

Choice C is wrong because magnesium sulfate does not prevent dehydration.It can cause fluid retention and pulmonary edema if given in excess.

A. Maintain the newborn in a reverse Trendelenburg position. B. Encourage family members to gently stroke the newborn’s face and head. C. Swaddle the newborn in a flexed position. D. Provide the newborn with visual stimulation.

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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Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with preeclampsia is admitted to the hospital and prescribed magnesium sulfate therapy. What is the purpose of administering magnesium sulfate to this patient?

Correct Answer is D

Explanation

The newborn of a patient suspected to have used drugs during the prenatal period is admitted to the nursery.The nurse caring for the newborn notes that the infant is beginning to exhibit signs of drug withdrawal.Which action should the nurse take?

Correct Answer is C

Explanation

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