What is the priority of the nurse in the immediate care of the ...

[big1devin]

What is the priority of the nurse in the immediate care of the newborn in the delivery room?
 
  a. Calculate Apgar score.
  b. Ensure a patent airway.
  c. Maintain body heat.
  d. Position the infant in a 30-degree head-down position.

Question 2

A nurse is reviewing normal and abnormal heart sounds. The nurse recognizes a child has an abnormal heart sound if:
 
  1. There is a sinus arrhythmia. (Heart rate is faster on inspiration and slower on expiration.)
  2. A third heart sound is heard.
  3. The S1 is heard best in the mitral area of the heart.
  4. The S1 and S2 heart sounds are muffled.

[cascooper22]

Answer to Question 1

B
Maintaining the ABCs is a nursing priority. Maintaining body heat is the second highest priority for the nursery nurse. Positioning the infant in a 30-degree head-down position may encourage aspiration after emesis.

Answer to Question 2

4
Rationale:
1. Sinus arrhythmia is normal in children.
2. A third heart sound is normal in children.
3. The S1 is heard best in the mitral area of the heart.
4. S1 and S2 heart sounds should be crisp. Muffling might indicate a heart defect of congestive heart failure.