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 D

Explanation

The correct answer is D. A client who experienced a cesarean birth 4 hr ago and reports pain. Pain after a cesarean birth could indicate complications such as infection or hemorrhage and should be addressed immediately.

A. Increased deposits of fat in the chest and shoulder area. B. Hyperinsulinemia. C. Brachial plexus injury. D. Increased blood viscosity.

Correct Answer is B

Explanation

Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice B rationale
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood. In the case of a term macrosomic newborn whose mother has poorly controlled type 2 diabetes, the baby’s pancreas may produce extra insulin in response to the mother’s high blood glucose levels. This excess insulin can delay surfactant production, which is needed for lung maturation, leading to respiratory distress syndrome.
Choice C rationale
Brachial plexus injury is a type of birth injury that can occur due to the baby’s large size and difficulty being born. However, it is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes.
Choice D rationale

Increased blood viscosity can occur in newborns of mothers with poorly controlled diabetes due to polycythemia (an abnormally high number of red blood cells). However, this is not the most likely cause of respiratory distress syndrome in a term macrosomic newborn.

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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

A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

Correct Answer is D

Explanation

What is the most likely cause of respiratory distress syndrome in a term macrosomic newborn whose mother has poorly controlled type 2 diabetes?

Correct Answer is B

Explanation

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