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
A. Supine hypotension typically occurs in the second or third trimester when the gravid uterus compresses the inferior vena cava.
B. Constipation is more common in the second and third trimesters due to hormonal changes and uterine pressure on the intestines.
C. Urinary frequency is common in the first trimester due to hormonal changes and increased blood flow to the kidneys, leading to increased urine production.
D. Heartburn is more prevalent in the second and third trimesters due to relaxation of the lower esophageal sphincter and upward pressure from the growing uterus.
Correct Answer is A
Explanation
Choice A rationale: This statement indicates that the client understands the teaching about managing hyperemesis gravidarum. Eating crackers before getting out of bed in the morning is a common strategy to help alleviate morning sickness and hyperemesis gravidarum. Eating small, bland, and easily digestible foods before rising from bed can help prevent nausea and vomiting.
Choice B rationale: Drinking water with meals is not a specific strategy for managing hyperemesis gravidarum. In some cases, consuming liquids with meals might worsen nausea in clients with severe morning sickness.
Choice C rationale: Limiting protein intake is not a recommended strategy for managing hyperemesis gravidarum. Adequate protein intake is essential during pregnancy for proper fetal development.
Choice D rationale: Eating every 6 hours might not be sufficient for managing hyperemesis gravidarum. Frequent, small meals and snacks are often recommended to help manage nausea and vomiting in pregnancy.
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