The most critical nursing action in caring for the newborn ...

[Kikoku]

The most critical nursing action in caring for the newborn immediately after birth is:
 
  a. Keeping the newborn's airway clear.
  b. Fostering parent-newborn attachment.
  c. Drying the newborn and wrapping the infant in a blanket.
  d. Administering eye drops and vitamin K.

Question 2

The nurse knows that the second stage of labor, the descent phase, has begun when:
 
  a. The amniotic membranes rupture.
  b. The cervix cannot be felt during a vaginal examination.
  c. The woman experiences a strong urge to bear down.
  d. The presenting part is below the ischial spines.

[juwms]

Answer to Question 1

ANS: A
The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-infant attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The nursing activities would be (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering the infant with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborn's physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the infant to the partner or mother when he or she is ready.

Answer to Question 2

ANS: C
During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation.

[Kikoku]

Thank you

[juwms]

No problemo