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: During phototherapy, it is essential to maintain adequate hydration and nutrition for the newborn. Encouraging frequent breastfeeding helps provide the baby with essential nutrients and fluids, which can be lost due to increased stooling caused by phototherapy.
Choice B rationale: The use of lotion on the newborn's skin during phototherapy is not recommended, as it may interfere with the effectiveness of the light therapy. The skin needs to be exposed to the light for the treatment to work.
Choice C rationale: Monitoring the newborn's blood glucose level is not directly related to phototherapy. Blood glucose monitoring may be necessary for specific medical reasons, but it is not a standard intervention during phototherapy.
Choice D rationale: During phototherapy, the newborn is usually placed in a supine (face-up) position to ensure maximum exposure of the skin to the phototherapy lights. The prone position is not recommended during phototherapy as it may reduce the effectiveness of the treatment.
Correct Answer is C
Explanation
Choice A rationale:
A gynaecoid pelvis is considered the most favorable pelvic shape for childbirth and is not a contributing cause of difficult, prolonged labor.
Choice B rationale:
A longitudinal fetal lie (baby's spine aligned with the mother's spine) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
Choice C rationale:
A persistent occiput posterior position (baby's head facing the mother's abdomen instead of her back) can be a contributing cause of difficult, prolonged labor and may lead to a severe backache for the mother.
Choice D rationale:
Fetal attitude in general flexion (baby's head flexed forward, chin to chest) is a normal and favorable presentation for birth and is not a contributing cause of difficult, prolonged labor.
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