A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?
Place the newborn in the Trendelenburg position.
Administer saline drops into the newborn's nares.
Suction the newborn's mouth with a bulb syringe.
Perform deep suctioning of the newborn's trachea with an endotracheal tube.
The Correct Answer is C
Choice A rationale: Placing the newborn in the Trendelenburg position (head down, feet up) is not recommended in this situation and can potentially cause harm.
Choice B rationale: While saline drops can help clear nasal congestion, the bubbling mucus is coming from the mouth and nose, and suctioning is more appropriate.
Choice C rationale: The bubbling mucus indicates the presence of mucus and amniotic fluid in the baby's airway, which could interfere with breathing. The first action should be to suction the newborn's mouth to clear the airway.
Choice D rationale: Performing deep suctioning with an endotracheal tube is an invasive procedure and is not necessary for clearing mucus from the newborn's mouth and nose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: This response is not supportive and may cause the client to feel pressured or inadequate. It is essential to be empathetic and understanding of the client's feelings and needs.
Choice B rationale: The nurse should encourage the client to begin breastfeeding and offer support if needed. This response does not promote the client's active involvement in caring for her newborn.
Choice C rationale: While breastfeeding is a natural process, it can be challenging for some women, especially in the early days. This response may minimize the client's concerns and emotions.
Choice D rationale: The nurse should be supportive and reassuring to the postpartum client. The client may be feeling overwhelmed or uncertain about breastfeeding, so offering assistance and staying with the client to help with the first feeding is an appropriate and compassionate response.
Correct Answer is C
Explanation
A. Supine hypotension typically occurs in the second or third trimester when the gravid uterus compresses the inferior vena cava.
B. Constipation is more common in the second and third trimesters due to hormonal changes and uterine pressure on the intestines.
C. Urinary frequency is common in the first trimester due to hormonal changes and increased blood flow to the kidneys, leading to increased urine production.
D. Heartburn is more prevalent in the second and third trimesters due to relaxation of the lower esophageal sphincter and upward pressure from the growing uterus.
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