A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?

"Babies usually breathe in and out through their noses so they can feed without choking."

"You are right. I will report the baby's small nasal openings to the pediatrician right away.*

*Everything about babies is small. It truly is amazing how everything works so well."

"The baby does rarely open his mouth but you can see that he isn't in any distress.

Answer and Explanation

The Correct Answer is A

A) "Babies usually breathe in and out through their noses so they can feed without choking.":
Newborns are obligate nasal breathers, meaning they primarily breathe through their noses rather than their mouths, which helps coordinate breathing with feeding. This nasal breathing mechanism helps prevent aspiration and ensures that babies can feed while still breathing. It is perfectly normal for a baby to primarily use their nose for breathing, especially in the early days of life, and no cause for concern should be raised about small nasal openings unless the baby is showing signs of respiratory distress.

B) "You are right. I will report the baby's small nasal openings to the pediatrician right away.":
A small nasal opening is common in newborns and is not usually a cause for alarm unless it interferes with breathing, feeding, or shows signs of a more significant anatomical issue. There is no immediate need to report it unless the baby is having trouble breathing or feeding. The nurse should offer reassurance instead.

C) "Everything about babies is small. It truly is amazing how everything works so well.":
While this response may seem comforting, it is not very informative. It dismisses the mother’s concern rather than providing a clear and educational explanation. Reassuring the mother with factual information about why babies breathe through their noses and how this works effectively for them would be more helpful.

D) "The baby does rarely open his mouth but you can see that he isn't in any distress.":
This response minimizes the importance of the mother’s question and doesn’t fully address her concern. While it’s true that babies rarely open their mouths to breathe, the explanation needs to focus on the physiological reasoning behind it. The nurse should also reassure the mother that nasal breathing is normal in newborns and not typically a concern unless signs of distress are present.

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Correct Answer is A

Explanation

A) Apply an ice pack to the perineum:
For a second-degree perineal laceration sustained during delivery, ice application is an important intervention within the first 24 hours to reduce swelling, pain, and inflammation in the perineal area. Ice packs help constrict blood vessels, decrease tissue edema, and provide analgesic effects. This intervention is most effective immediately after delivery and within the first 2-4 hours to help manage pain and swelling at the site of the laceration.

B) Teach the woman to insert nothing into her rectum:
While it is true that women with perineal lacerations should avoid rectal trauma or anything inserted into the rectum (e.g., rectal thermometers, suppositories) for a period of time, this is not the most urgent or immediate action for this patient. The primary concern at this point is managing the acute symptoms related to the laceration (e.g., swelling, pain), which is best managed with ice packs and other measures. Teaching about avoiding rectal insertion would be important later in the postpartum period.
C) Advise the woman to sit on a pillow:
While sitting on a pillow can reduce pressure on the perineum and help with comfort, it is not the most immediate intervention for this woman, especially in the first few hours postpartum. The priority should be addressing swelling and pain associated with the perineal laceration, which is best managed with ice, as it helps with the acute management of the injury.

D) Advise the woman to use sitz bath after each void:
A sitz bath can be helpful for perineal healing in the postpartum period, but it is typically recommended after the first 24 hours post-delivery, after the initial swelling has gone down. During the first few hours to days postpartum, ice packs are generally the preferred intervention to manage swelling and pain, while sitz baths are often advised later to promote comfort, healing, and circulation in the perineum.

A. Clear fluids from airway B. Immediately assess and bathe baby C. Dry infant thoroughly D. Place baby skin to skin E. Give erythromycin ointment in baby's eyes

Correct Answer is ["A","C","D"]

Explanation

A) Clear fluids from airway:
Immediately clearing the infant's airway is one of the first steps in stabilizing the newborn after birth. This ensures the infant can breathe freely, reducing the risk of aspiration or airway obstruction. Suctioning the mouth and nose with a bulb syringe or suction catheter is the usual practice, especially if there are visible fluids or secretions. This intervention is critical for ensuring the infant's respiratory function.

B) Immediately assess and bathe baby:
While assessing the newborn is vital, it is not the immediate priority. The first step in stabilization is ensuring the newborn’s airway is clear, followed by efforts to prevent heat loss. Bathing should be delayed until after the baby is stable, and drying the baby thoroughly should be done as the first action to prevent hypothermia.

C) Dry infant thoroughly:
Drying the newborn thoroughly after birth is essential for preventing heat loss. Wet skin can quickly lead to hypothermia, and drying helps maintain the infant's body temperature. This intervention is vital for stabilizing the newborn and ensuring thermoregulation in the first moments of life.

D) Place baby skin to skin:
Skin-to-skin contact is a fundamental practice immediately after birth. It promotes bonding, helps regulate the infant's temperature, supports successful breastfeeding initiation, and stabilizes vital signs like heart rate and blood sugar levels. The mother’s body heat helps the baby maintain a normal temperature, which is especially important right after birth.

E) Give erythromycin ointment in baby’s eyes:
While applying erythromycin ointment to the baby’s eyes is a standard practice to prevent neonatal conjunctivitis (especially from gonorrhea or chlamydia), it is not a priority for immediate stabilization. This step is typically performed later, after the newborn is stable, and thermoregulation is addressed. The primary focus should be on airway clearance, drying, and promoting skin-to-skin contact first.

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A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postpartum patient who experienced a second-degree laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?

Correct Answer is A

Explanation

Name 3 nursing interventions that promote stabilization of the newborn immediately after birth:

Correct Answer is ["A","C","D"]

Explanation

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A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?