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 D
Explanation
Choice A rationale: Eight months is too early to transition to whole milk. At this age, infants still need the complete nutrition provided by breast milk or formula.
Choice B rationale: Ten months is still too early for transitioning to whole milk. Breast milk or formula should be the primary source of nutrition until around 12 months of age.
Choice C rationale: At 6 months of age, infants are usually just starting to introduce solid foods, but breast milk or formula remains the primary source of nutrition. Transitioning to whole milk at this age is not recommended.
Choice D rationale: The American Academy of Pediatrics (AAP) recommends transitioning from breast milk or formula to whole cow's milk at around 12 months of age. Before that age, breast milk or formula provides essential nutrients for the baby's growth and development.
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