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 C
Explanation
Choice A rationale: Placing elbow restraints is not a recommended practice for preterm newborns. Restraints are used in some cases to prevent the baby from pulling on tubes or lines, but it is not primarily for energy conservation.
Choice B rationale: While frequent position changes are important to prevent pressure ulcers and promote comfort, they may not necessarily help conserve energy in a preterm newborn.
Choice C rationale: Preterm newborns have limited energy reserves, and conserving energy is essential for their growth and development. Clustering care activities involves combining nursing care tasks to allow for longer periods of uninterrupted rest for the baby. This approach reduces the baby's energy expenditure and promotes better weight gain and stability.
Choice D rationale: While gentle touch and massage can be beneficial for preterm newborns to promote bonding and relaxation, it may not directly conserve energy as cluster care does.
Correct Answer is C
Explanation
Choice A rationale: This statement is correct. Burping the baby halfway through each feeding can help release air and prevent discomfort from gas build-up.
Choice B rationale: This statement is correct. It is essential to watch for signs of satiety in the baby, such as slowing down sucking, turning away from the bottle, or becoming relaxed.
Stopping the feeding when the baby is full helps prevent overfeeding.
Choice C rationale: This statement indicates a need for further teaching. The duration of feeding can vary for different babies, and it is not advisable to limit the feeding time to a specific duration like 10 to 15 minutes. Babies have different feeding patterns and may take longer or shorter periods to finish a feeding. It is essential to allow the baby to feed until they are full and satisfied.
Choice D rationale: This statement is correct. It is safe and appropriate to give formula to the baby at room temperature, or it can be warmed if the baby prefers it that way. However, never heat the formula in the microwave as it can create hot spots that may burn the baby's mouth. Instead, warm the formula by placing the bottle in a bowl of warm water. Always test the temperature on the inside of your wrist before feeding the baby to ensure it's not too hot.
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