Level: Clinical
Difficulty: Medium
Subtopic: Newborn transition
NCLEX: A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A 38-week newborn on the mother-baby unit is being evaluated for newborn adaptation after birth. Assessment data include temperature 36.1°C (97°F) after the first bath. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Visitor concerns before physiologic stability.
C. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
B. Visitor concerns before physiologic stability.
C. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale
Correct answer: D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.