A nurse is assessing a newborn immediately after a scheduled cesarean delivery. Which of the following assessments should be the nurse’s priority?
Accidental lacerations.
Acrocyanosis.
Respiratory distress.
Hypothermia.
The Correct Answer is C
Choice A rationale
While accidental lacerations can occur during a cesarean delivery, they are not typically the primary concern immediately after delivery.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a priority concern immediately after delivery.
Choice C rationale
Respiratory distress is a priority concern in a newborn after a cesarean delivery. Newborns delivered by cesarean may have transient tachypnea of the newborn (TTN), a condition characterized by rapid breathing during the first few hours of life.
Choice D rationale
While hypothermia is a concern in newborns, it is not typically the immediate priority following a cesarean delivery.
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Correct Answer is D
Explanation
Choice A rationale
Fetal hyperinsulinemia is a condition where the fetus produces an excess amount of insulin, and it is more commonly associated with macrosomia (large for gestational age) rather than being small for gestational age.
Choice B rationale
Preterm delivery can result in a baby being small for birth weight, but it does not cause a baby to be small for gestational age. Small for gestational age means the baby’s weight is less than the 10th percentile for their gestational age.
Choice C rationale
Perinatal asphyxia, a lack of oxygen before, during, or just after birth, does not cause a baby to be small for gestational age. It can cause other complications, such as organ damage.
Choice D rationale
Placental inefficiency, where the placenta does not work as well as it should, can cause a baby to be small for gestational age. This is because the baby may not receive enough oxygen and nutrients from the mother.
Correct Answer is C
Explanation
Choice A rationale
The fundus should not be soft or to the right of the umbilicus 12 hours postpartum. A soft or displaced fundus could indicate uterine atony or a full bladder, both of which require intervention.
Choice B rationale
The fundus should not be soft or above the umbilicus 12 hours postpartum. This could indicate uterine atony, which could lead to postpartum hemorrhage.
Choice C rationale
The fundus should be firm and at the level of the umbilicus 12 hours postpartum. This indicates that the uterus is contracting properly to prevent excessive bleeding.
Choice D rationale
The fundus should not be to the left of the umbilicus 12 hours postpartum. This could indicate a full bladder, which can displace the uterus and interfere with uterine contractions
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