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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Vaginal discharge, or leukorrhea, often increases during pregnancy due to higher levels of estrogen and greater blood flow to the vaginal area. It does not typically decrease before labor.
Choice B rationale
Weight gain is expected during pregnancy, but a sudden gain of 0.5 to 1.3 kg is not a typical sign that labor is about to start.
Choice C rationale
Urinary retention is not a typical sign that labor is about to start. In fact, many women find that they need to urinate more frequently as labor approaches, due to increased pressure on the bladder.
Choice D rationale
A surge of energy, often called “nesting,” can be a sign that labor is about to start. Some women experience a burst of energy and the desire to prepare their home for the baby in the days or hours before labor begins.
Correct Answer is ["A","C"]
Explanation
A nurse is caring for a client who is 2 days postpartum.
The client is a Gravida 4 Para 3 who had a forceps-assisted birth with epidural anesthesia at 40 weeks of gestation. She had a second degree mediolateral perineal laceration with repair, and the placenta was manually extracted.
The estimated blood loss was 600 mL. Complete the diagram by dragging from the choices below to specify what condition the client is experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
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