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 B
Explanation
Choice A rationale
Betamethasone does not typically increase the fetal heart rate14.
Choice B rationale
Betamethasone is often given to pregnant women who are at risk of preterm birth to promote fetal lung maturity. It helps speed up the development of the baby’s lungs and other organs14.
Choice C rationale
Betamethasone is not used to stop preterm labor contractions14.
Choice D rationale
Betamethasone does not halt cervical dilation14.
Correct Answer is C
Explanation
The correct answer is choiceC. Respiratory rate.
Choice A rationale:
Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus.However, when administering magnesium sulfate, the primary concern is the mother’s respiratory status due to the risk of respiratory depression, which can be a side effect of the medication.
Choice B rationale:
While bowel sounds are an important part of a comprehensive assessment, they are not the primary concern when administering magnesium sulfate.Magnesium sulfate primarily affects the neuromuscular and respiratory systems.
Choice C rationale:
Respiratory rate is the primary nursing assessment for a client receiving magnesium sulfate IV.Magnesium sulfate can cause respiratory depression, so it is essential to monitor the client’s respiratory status closely to detect any signs of respiratory compromise early.
Choice D rationale:
Monitoring temperature is important in any clinical setting, but it is not the primary concern when administering magnesium sulfate.The primary focus should be on the respiratory rate due to the potential for respiratory depression.
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