Question 1:
The priority nursing care of the newborn immediately after birth includes all
except:.
A. Support thermoregulation.
B. Identify the
... [Show More] infant.
C. Promote normal respirations.
D. Announcement of the delivery.
Show correct answer and explanation
Explanation
The correct answer is choice D. Announcement of the delivery.
Choice A reason:
Support thermoregulation is a priority in nursing care of the newborn
immediately after birth. Newborns are at risk of hypothermia because they have
a large surface area to body mass ratio, thin skin, and limited subcutaneous fat.
To prevent heat loss, newborns should be dried thoroughly, placed skin-to-skin
with the mother, and covered with warm blankets.
Choice B reason:
Identifying the infant is a priority nursing care of the newborn immediately after
birth. Newborns should be identified with identification bands that match those of
the mother and father or significant other. This helps prevent errors in infant
identification and ensures safety and security.
Choice C reason:
Promoting normal respirations is a priority nursing care of the newborn
immediately after birth. Newborns need to establish effective breathing patterns
to ensure adequate oxygenation and prevent complications such as respiratory
distress syndrome or meconium aspiration syndrome. To promote normal
respirations, newborns should be suctioned gently to clear the airway, stimulated
to cry, and assessed for signs of distress.
Choice D reason:
Announcement of the delivery is not a priority in nursing care of the newborn
immediately after birth. While it may be a joyful moment for the parents and
family, it does not affect the health and well-being of the newborn. Therefore, it
can be done later after the essential newborn care has been completed.
Question 2:
A mother is upset because her newborn has lost 6 ounces since birth 2 days
ago. The nurse informs the mother that it is normal for a newborn to lose which
percentage of their birth weight within the first week of life?
A. 10% to 15% of their birth weight.
B. 20% of their birth weight.
C. 15% to 18% of their birth weight.
D. 5% to 10% of their birth weight.
Show correct answer and explanation
Explanation
Choice A reason:
10% to 15% of their birth weight. This is incorrect because this range is too high
for a normal newborn weight loss. Losing more than 10% of their birth weight
may indicate dehydration, inadequate feeding, or other problems. • Choice B
reason:
20% of their birth weight. This is incorrect because this percentage is way too
high for a normal newborn weight loss. Losing 20% of their birth weight would
be a serious sign of illness or malnutrition. • Choice C reason:
15% to 18% of their birth weight. This is incorrect because this range is also too
high for a normal newborn weight loss. Losing 15% to 18% of their birth weight
would be a cause for concern and require further evaluation. • Choice D reason:
5% to 10% of their birth weight. This is correct because this range is within the
normal limits for a newborn weight loss. Newborns lose some weight as a result
of insufficient caloric intake, fluid loss, and metabolic adjustments in the first
week after birth. They usually regain their birth weight by the second week.
Question 3:
The nurse notes a nonreassuring pattern of the fetal heart rate. The mother is
already lying on her left side. What nursing action is indicated?
A. Change her position to the right side.
B. Place a wedge under the left hip.
C. Lower the head of the bed.
D. Place the mother in a Trendelenburg position.
Show correct answer and explanation
Explanation
Choice A reason:
Change her position to the right side. This is not correct because changing the
position to the right side may not improve the fetal blood flow and
oxygenation. The left lateral position is usually preferred because it reduces
the compression of the inferior vena cava and the aorta by the gravid uterus.
• Choice B reason:
Place a wedge under the left hip. This is not correct because placing a wedge
under the left hip may increase the pressure on the vena cava and reduce the
venous return to the heart. This may worsen the fetal hypoxia and acidosis.
• Choice C reason:
Lower the head of the bed. This is not correct because lowering the head of the
bed may increase the uterine perfusion pressure and decrease the placental
blood flow. This may also aggravate the fetal distress. • Choice D reason:
Place the mother in a Trendelenburg position. This is correct because placing
the mother in a Trendelenburg position may improve the fetal blood flow and
oxygenation by shifting the uterus away from the vena cava and increasing
the venous return to the heart. This may also reduce the uterine contractions
and relieve the cord compression.
Question 4:
The nurse is inspecting a male newborn's genitalia. Which action should the
nurse avoid when conducting this assessment?
A. Inspecting if the urethral opening appears circular.
B. Retracting the foreskin over the glans to assess for secretions.
C. Palpating if testes are descended into the scrotal sac. [Show Less]