A 42-week gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is most critical at this time?
Ophthalmic assessment to check for conjunctival irritation.
Rectal temperature to assess for septic hyperthermia.
Bath to remove meconium-stained fluid from the skin.
Respiratory evaluation to monitor for respiratory distress.
The Correct Answer is D
Choice A rationale
While conjunctival irritation could occur from exposure to irritants, it is not a primary concern in this case. Respiratory complications take precedence due to the risk of aspiration from meconium-stained fluid.
Choice B rationale
Rectal temperature assessment for hyperthermia is important but not critical in the immediate scenario. Respiratory distress monitoring is more urgent due to the association with meconium aspiration syndrome.
Choice C rationale
Bathing to remove meconium-stained fluid minimizes infection risk. However, respiratory assessment is more critical due to the severe pulmonary complications associated with meconium aspiration.
Choice D rationale
Meconium-stained amniotic fluid increases the risk of aspiration, leading to respiratory distress. Early respiratory evaluation prevents hypoxia, pulmonary hypertension, or pneumonitis, which are serious complications in neonates.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Placing the infant prone increases the risk of sudden infant death syndrome (SIDS), particularly for neonates. Supine positioning reduces this risk and is supported by evidence-based guidelines for infant care.
Choice B rationale
Tightly swaddling and dimming lights mimic the in utero environment, reducing overstimulation and promoting self-regulation. This is especially vital for neonates with neonatal abstinence syndrome (NAS), who are sensitive to external stimuli.
Choice C rationale
Providing excessive stimulation can exacerbate stress responses in neonates with NAS. This may manifest as increased crying, irritability, and tachycardia, worsening their fragile physiological state.
Choice D rationale
Feeding half-strength formula is not advised as it may cause inadequate caloric intake and impaired weight gain. Normal feeding practices, with proper intervals, are crucial to supporting healthy growth and development.
Correct Answer is A
Explanation
Choice A rationale
Urine output of 40 mL in 8 hours indicates oliguria, suggesting inadequate renal perfusion. Normal urine output is 30 mL/hour or greater. This could signify hypovolemia or renal compromise post-hemorrhage.
Choice B rationale
A drop in hematocrit of 2% may be expected postpartum and is not immediately concerning unless accompanied by hemodynamic instability or symptoms of anemia like dizziness or fatigue.
Choice C rationale
A 2 lb weight decrease postpartum is normal due to fluid shifts and diuresis. It does not indicate an emergent condition requiring immediate reporting to the obstetrician.
Choice D rationale
A pulse rate of 68 beats per minute is within the normal adult range of 60 to 100 beats per minute and is not typically concerning post-delivery.
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