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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a lateral position can help improve blood flow to the uterus and placenta, which can help stabilize the client’s blood pressure and the fetal heart rate.
Choice B rationale
Monitoring vital signs every 5 minutes is important, but the priority action is to address the client’s low blood pressure, which can compromise blood flow to the fetus.
Choice C rationale
Elevating the client’s legs can help increase venous return and improve blood pressure, but it is not the priority action in this situation.
Choice D rationale
Notifying the provider is important, but the nurse should first take action to stabilize the client’s condition.
Correct Answer is A
Explanation
Choice A rationale
When breastfeeding, it is recommended that the mother places her nipple and some of the areola into the baby’s mouth. This allows the baby to have a good latch, which is important for effective breastfeeding.
Choice B rationale
While it is important for the baby to take a good portion of the breast into their mouth, suggesting to include some breast tissue beyond the areola might be too much for a newborn’s small mouth.
Choice C rationale
This statement is not entirely accurate. While a newborn’s mouth is small, they should take as much of the nipple and areola into their mouth as possible to ensure effective breastfeeding.
Choice D rationale
While babies have certain instincts, they and their mothers often need guidance and practice to achieve a good latch and effective breastfeeding.
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