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 B
Explanation
A. SGA newborns often have increased circulating RBCs (polycythemia) due to chronic hypoxia in utero, not decreased RBCs.
B. Blood glucose instability (hypoglycemia) is common in SGA newborns due to decreased glycogen stores and increased metabolic demands.
C. Retinopathy of prematurity is more commonly associated with preterm infants and prolonged oxygen therapy rather than SGA status.
D. SGA newborns typically have a scaphoid (sunken) rather than a well-rounded abdomen due to decreased subcutaneous fat stores.
Correct Answer is D
Explanation
A. Breast engorgement typically occurs around days 3 to 5 postpartum, so encouraging frequent nursing at 14 hours postpartum will not impact milk production at this stage.
B. A temperature of 37.7°C (100°F) is a normal postpartum finding due to dehydration and hormonal changes. It does not require reporting unless it exceeds 38°C (100.4°F).
C. Increasing IV fluids is not necessary unless there is evidence of dehydration or another medical indication.
D. A slightly deviated fundus suggests bladder distension, which can interfere with uterine involution. Asking the client to empty her bladder helps the uterus contract properly and prevents complications such as postpartum hemorrhage.
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