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 A
Explanation
Choice A rationale: Drying the newborn and covering the head are essential steps in the immediate care of a newborn after birth. This helps prevent heat loss and promotes thermal stability for the baby.
Choice B rationale: Stimulating the newborn to cry is not the first priority in the immediate post-birth care. Drying and keeping the baby warm are more critical at this stage.
Choice C rationale: Clearing the respiratory tract may be necessary if there are signs of respiratory distress, but it is not the first action in the routine care of a newborn immediately after delivery.
Choice D rationale: Clamping the umbilical cord is usually done after the immediate care of the newborn is addressed, and it is not the first step in the initial care following a vaginal delivery.
Correct Answer is B
Explanation
Choice A rationale: An increase in breast milk production is a normal physiological response during breastfeeding and does not indicate mastitis.
Choice B rationale: Mastitis is an inflammation of the breast tissue, usually caused by infection. It commonly occurs in breastfeeding women and is characterized by redness, warmth, swelling, and pain in one breast. The affected breast may also be tender and sore to the touch.
Choice C rationale: Swelling in both breasts is a common occurrence during the early days of breastfeeding as the milk supply adjusts to the baby's needs. It is not specific to mastitis.
Choice D rationale: Cracked and bleeding nipples can be a result of improper latch or positioning during breastfeeding, but they are not specific to mastitis.
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