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; Erythema toxicum is a common rash that appears in many newborns and is not a cause for concern. It presents as small red bumps or pustules on the skin and usually resolves on its own without treatment.
Choice B rationale: A Mongolian spot is a birthmark that appears as a bluish-gray or bruise-like patch on the baby's skin, often on the back or buttocks. It is a benign condition and does not require any medical intervention.
Choice C rationale: Telangiectatic nevi, also known as "stork bites" or "angel kisses," are flat, pink, or red birthmarks that are common in newborns. They are usually found on the eyelids, forehead, and back of the neck. These birthmarks are harmless and typically fade over time without treatment.
Choice D rationale: Jaundice is a common condition in newborns and is caused by elevated levels of bilirubin in the blood. In most cases, mild jaundice is not harmful and resolves on its own. However, if the baby's skin and sclera (white part of the eyes) show significant yellowing, it may indicate a higher level of bilirubin, which can lead to complications if not properly managed. Therefore, the nurse should report this finding to the provider for further evaluation and appropriate treatment if necessary.
Correct Answer is D
Explanation
Choice A rationale: While this is an important action, it is not the first priority immediately after delivery. The priority is to ensure the newborn's breathing and warmth.
Choice B rationale: Assessing the gestational age of the newborn is important but can be done after ensuring the newborn's immediate well-being.
Choice C rationale: This is important for proper identification, but it can be done after the newborn is stabilized.
Choice D rationale: The first action after delivery is to dry the newborn to prevent hypothermia and stimulate breathing. Drying the baby helps remove amniotic fluid and stimulates the baby's reflexes, making it the priority action.
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