The nurse working in the delivery room assesses a newborn infant ...

[bclement10]

The nurse working in the delivery room assesses a newborn infant delivered vaginally. The infant has a strong cry, is moving all extremities vigorously, and its color is pink. Which action by the nurse is the priority?
 
  1. Stimulate the infant.
  2. Encourage infant-maternal bonding.
  3. Dry the infant.
  4. Administer oxygen.

Question 2

Which set of vital signs obtained by the nurse would indicate the need to notify the health care provider?
 
  1. Postoperative client who had abdominal surgery has vital signs of 99.8 F oral; 120; 10; 108/56.
  2. Pulse oximeter probe on the finger of a client diagnosed with hypotension reads 72.
  3. Client who successfully walked the entire hallway after 2 weeks of bed rest has vital signs of 98.8 F oral; 108; 22; 140/88.
  4. Client with no significant medical history who has recently been selected to be a member of the U.S. Olympic swimming team has vital signs of 98.6 F oral; 52; 12; 98/52.

[morrie123456]

Answer to Question 1

Correct Answer: 3

The nurse's priority action is to dry the infant, because heat can be lost through condensation if the infant's skin is wet. The infant is vigorous, and so does not require stimulation; color is pink, and so oxygen is not needed; and bonding should be fostered as soon as the infant is dried.

Answer to Question 2

Correct Answer: 1

The postoperative client is demonstrating tachycardia and mildly depressed respirations, which could indicate blood loss or dehydration, which is further supported by the mildly elevated temperature. The client with hypotension and a low oxygen saturation reading might be seeing the result of poor perfusion to the sensor site. The sensor should be moved and the client further assessed prior to notifying the primary care provider. It would be expected that the client on bed rest who walked the hall for the first time could be mildly tachycardic and tachypneic. Athletic individuals who are well conditioned often have reduced heart rate and blood pressures, so this client's vital signs might be normal for this individual.

[bclement10]

Excellent

[AmberC1996]

TYSM