Question: A client gives birth to a full-term newborn with an 8/9 Apgar score. List the initial nursing care in order of their priority.
1. Place in heated crib
2. Perform physical assessment
3. Apply identification band to mother and infant
4. Instill antibiotic prophylaxis and administer vitamin K
Answer: 1, 3, 2, 4
Rationale: The newborn's thermoregulation mechanism is immature and an exogenous heat source is needed. Once the Apgar score has confirmed a healthy newborn and the infant is warm, the next step is to identify both mother and infant using bands with the same numbers. The newborn is now ready to be protected from contracting ophthalmia neonatorum and Chlamydia with an antibiotic, and hemorrhagic disease of the newborn with vitamin K.
Clinical Area: Childbearing and Women’s Health Nursing
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis
Nursing Process: Planning
This week’s NCLEX exam practice question can be found in:
Nugent: Mosby's Review Questions for the NCLEX-RN Exam, 7th edition, Chapter 4, page 327, Question # 319
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