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.

Answer and Explanation

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 A

Explanation

Choice A rationale
Cervical dilation is a positive sign of labor. During labor, the cervix dilates to allow the baby to pass through the birth canal. This is a definitive sign that labor is occurring.
Choice B rationale
Amniotic fluid in the vaginal vault could indicate rupture of membranes, but it does not confirm labor. Labor may or may not be present when the membranes rupture.
Choice C rationale
Pain above the umbilicus is not a typical sign of labor. Labor pain is usually felt in the lower back and lower abdomen.
Choice D rationale
Brownish vaginal discharge could be a sign of “bloody show,” which can occur as labor approaches. However, it does not confirm that labor is occurring.

A. Deltoid B. Vastus lateralis C. Ventrogluteal D. Dorsogluteal .

Correct Answer is B

Explanation

Choice A rationale
The deltoid muscle is not typically used for intramuscular injections in infants due to its small size.

Choice B rationale
The vastus lateralis muscle is one of the preferred sites for intramuscular injections in infants, including the vitamin K injection. This muscle is large enough to absorb the medication, and injections here carry less risk of hitting a nerve or blood vessel.
Choice C rationale
The ventrogluteal muscle is not typically used for intramuscular injections in infants. This site is often used in older children and adults.
Choice D rationale
The dorsogluteal site is not recommended for intramuscular injections due to the risk of damaging the sciatic nerve.

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A nurse is assessing a newborn immediately after a scheduled cesarean delivery. Which of the following assessments should be the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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