The nurse is caring for a newborn immediately after delivery. Which of the following actions would be appropriate?
The nurse is caring for a newborn immediately after delivery. Which of the following actions would be appropriate?
A. Perform APGAR assessment at five and ten minutes
[16%]
B. Suctions the nose then the mouth
[32%]
C. Administer RhoGAM intramuscularly
[1%]
D. Place the infant skin to skin with a parent
[52%]
Statistics
Subject/Lesson
Subject
Maternal & Newborn Health
Lesson
Newborn
Client Need
Test Plan
Health Promotion and Maintenance
Related Topic
Ante/Intra/Postpartum and Newborn Care
Item Type
Item Type
Application
Explanation
Choice D is correct. A newborn is at risk of cold stress during the first few hours of post-intrauterine life. The nurse should dry the newborn thoroughly and place the newborn skin-to-skin with a parent.
Choice A is incorrect. While performing the APGAR assessment is an essential part of newborn care, it is usually done at one and five minutes after birth, not at five and ten minutes.
Choice B is incorrect. If suctioning is indicated, the nurse should suction the mouth, then the nose, not the nose, then the mouth. Routine suctioning is not always necessary, and it is not the primary action immediately after delivery.
Choice C is incorrect. RhoGAM is indicated for Rh-negative mothers – not newborns. Medications administered to a newborn include intramuscular Vitamin K and erythromycin eye ointment.
Additional Info
✓ Placing the newborn skin to skin with a parent, also known as kangaroo care, is a beneficial practice for various reasons. It helps regulate the baby's temperature, promotes bonding between the infant and parent, and supports early initiation of breastfeeding. Skin-to-skin contact has been associated with numerous positive outcomes for both the newborn and the parent.
✓ When caring for a newborn, the nurse should perform an APGAR assessment at one and five minutes. The higher the score, the more stable the infant. Scores 7 to 10 are reassuring.
✓ The APGAR assessment evaluates a newborn's color, heart rate, reflexes, muscle tone, and respiration.
✓ Suctioning is only performed if indicated. If indicated, the correct sequence for suctioning a newborn is the mouth, then the nose.
