The most critical nursing action when caring for a newborn ...

[jon_i]

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

Question 2

The nurse is performing an assessment on a 4-hour old newborn. Findings include temperature 36.2 C (97.2 F), heart rate 162 beats/minute, respiratory rate 62 breaths/minute with 20-second pauses. The nurse's first action should be to:
 
  a. Notify the health care provider.
  b. Recheck vital signs in 1 hour.
  c. Document findings as normal.
  d. Return the newborn to the mother's room for rooming-in.

[vickyvicksss]

Answer to Question 1

ANS: D
To adapt to extrauterine life, the newborn must quickly breathe and maintain respirations and replace fluid in the lungs with air. Mucus and fluid must be suctioned from the newborn's airway to facilitate breathing and prevent respiratory distress. The newborn breathes through his or her nose, and any nasal obstruction can cause respiratory difficulty because the newborn will not typically mouth breathe.

Answer to Question 2

ANS: A
Although all vital signs are barely abnormal (normal: temperature 36.5 C 97.7 F, heart rate 110-160 beats/minute, respiratory rate 30-60 breaths/minute with 5- to 15-second pauses), the health care provider should be notified because these may be early signs of cold stress or other abnormality. The infant should be warmed before rechecking vital signs. The infant may be returned to its mother for rooming-in but only after health care provider has been notified.

[jon_i]

Thank you

[vickyvicksss]

Happy to help you