A nurse is assessing a newborn immediately following a scheduled cesarean delivery.

Which of the following assessments is the nurse’s priority?

Respiratory distress

Acrocyanosis.

Accidental lacerations

Hypothermia

Answer and Explanation

The Correct Answer is A

A.   Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B.   Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D.   While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.

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Correct Answer is C

Explanation

A. Turning the newborn on his side may be done after suctioning but is not the initial priority.
B. Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C.Suctioning the mouth is a necessary step to ensure effective breathing.
D. Suctioningthe nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.

A. The nurse should immediately notify the pediatrician for this emergency situation B. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth C. The neonate must have aspirated surfactant D. If this baby was born vaginally, then a pneumothorax could be indicated

Correct Answer is B

Explanation

A. Moist lung sounds in this context are not indicative of an emergency situation requiring immediate notification of the pediatrician.
B. Moist lung sounds in a baby born by cesarean section are common and may be due to retained lung fluid, often resolving within the first 24 hours after birth. This is because the baby does not experience the same compression of the chest during delivery as a baby born vaginally, which helps to expel some of the fluid from the lungs.
C. Aspiration of surfactant is not a common or likely occurrence.
D. Moist lung sounds are not typically indicative of a pneumothorax, especially in the absence of other signs and symptoms.

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

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A nurse is assessing a newborn immediately following a scheduled cesarean delivery.

Which of the following assessments is the nurse’s priority?