Question

The priority nursing care of the newborn immediately after birth includes all except:

Answer 1

Correct Answers:

Announcement of the delivery.

Rationale :

📣 Immediate care of the newborn after birth includes: supporting respirations, maintaining thermoregulation, and ensuring identification.

📣 While announcing the delivery is important for documentation and family communication, it is not a clinical priority.

📣 The nurse must prioritize airway, breathing, and temperature stabilization first.

📣 Delayed or omitted announcement will not impact the newborn's physiologic transition.

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Answer 2

Correct Answers:

5% to 10% of their birth weight.

Rationale :

⚖️ It is normal for a newborn to lose 5–10% of birth weight in the first week of life due to fluid shifts and caloric adjustment.

⚖️ Weight should be regained by 10–14 days postpartum.

⚖️ Losses over 10% may indicate feeding issues or dehydration.

⚖️ The nurse should educate and reassure the mother this is expected and temporary.

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Answer 3

Correct Answers:

Place a wedge under the left hip.

Rationale :

🛌 The best response to non-reassuring FHR and hypotension is improving uteroplacental perfusion.

🛌 Placing a wedge relieves pressure on the inferior vena cava, enhancing blood return and oxygen delivery to the fetus.

🛌 Trendelenburg and lowering the head are inappropriate and may worsen perfusion.

🛌 If already on the left side, a wedge enhances tilt without full repositioning.

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Answer 4

Correct Answers:

Retracting the foreskin over the glans to assess for secretions.

Rationale :

🚫 Do not forcibly retract the foreskin of a newborn — it can lead to pain, bleeding, or injury.

🚫 Retraction can cause adhesions or infection in uncircumcised infants.

🚫 Foreskin typically becomes retractable over time, usually by school age.

🚫 Inspect, but avoid manipulation beyond natural separation.

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Answer 5

Correct Answers:

Move infant away from blowing fan.

Rationale :

🌬️ Convection heat loss occurs when air currents (like fans) draw heat away from the newborn.

🌬️ Prevent this by removing the infant from drafts or using closed incubators.

🌬️ Other options help with evaporation or radiation heat loss, not convection.

🌬️ Environmental control is crucial for thermoregulation in newborns.

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Answer 6

Correct Answers:

Tonic neck reflex.

Rationale :

🧠 The tonic neck reflex (or "fencer’s pose") occurs when the infant’s head is turned — the limbs on that side extend, the opposite side flexes.

🧠 It helps develop hand-eye coordination and is a sign of neurologic integrity.

🧠 It disappears around 4–6 months of age.

🧠 Moro and startle involve extension and recoil; Babinski is toe-fanning from sole stimulation.

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Answer 7

Correct Answers:

Assist the client to turn onto her side.

Rationale :

📉 A BP of 82/52 mm Hg indicates hypotension, a common side effect of epidural or aortocaval compression.

📉 Turning to the side improves venous return and fetal oxygenation.

📉 This position may correct FHR and maternal BP without medications.

📉 Upright position would worsen perfusion, and immediate delivery isn’t yet indicated.

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Answer 8

Correct Answers:

Variable decelerations.

Rationale :

📊 Variable decelerations on a fetal heart monitor are caused by umbilical cord compression.

📊 They appear as sudden, irregular drops in FHR that vary in timing and shape.

📊 Unlike early or late decels, these are not linked to contractions.

📊 Nurses should intervene with repositioning and oxygen if persistent.

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Answer 9

Correct Answers:

Assist the client with breathing and imagery techniques in an attempt to calm her down.

Rationale :

🧘 Nonpharmacologic techniques like breathing, imagery, and touch are key parts of labor support.

🧘 The husband is understandably distressed; nurse helps both by focusing on calming the client.

🧘 Pain scale is useful, but not the priority here.

🧘 There’s no need to call the provider or dismiss the partner's concern.

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Answer 10

Correct Answers:

Have the client pant during the next contractions.

Rationale :

😮‍💨 Panting helps resist the urge to push prematurely, preventing cervical trauma if full dilation hasn’t occurred.

😮‍💨 At 7 cm, the client is in active labor but not ready to push.

😮‍💨 Premature pushing may cause edema and complications.

😮‍💨 Crowning or full dilation must be confirmed before allowing pushing.

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QLexNursing

1 :
The priority nursing care of the newborn immediately after birth includes all except:

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?

3 :
The nurse notes a no reassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?

4 :
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?

5 :
To prevent heat loss from convection in a newborn, which action by the nurse is best?

6 :
Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?

8 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

9 :
A prim gravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?

10 :
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

QLexNursing

1 : The priority nursing care of the newborn immediately after birth includes all except:

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?

3 : The nurse notes a no reassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?

4 : The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?

5 : To prevent heat loss from convection in a newborn, which action by the nurse is best?

6 : Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?

8 : A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

9 : A prim gravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?

10 : A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

1 :
The priority nursing care of the newborn immediately after birth includes all except:

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?

3 :
The nurse notes a no reassuring pattern of the fetal heart rate. The mother is already lying on her left side. What nursing action is indicated?

4 :
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?

5 :
To prevent heat loss from convection in a newborn, which action by the nurse is best?

6 :
Which newborn reflex elicits the following reaction: Head turns to one side - the way the head is facing, the arm/leg is stretched out while the other is bent?

8 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

9 :
A prim gravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?

10 :
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?