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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale: RhoGAM is not given solely based on blood loss. It is administered to prevent Rh isoimmunization, which is unrelated to the amount of blood loss.
Choice B rationale: If the client has previously given birth to an Rh-negative infant, she is already sensitized and would not require RhoGAM for this current ectopic pregnancy.
Choice C rationale: Rho(D) Immune globulin (RhoGAM) is given to Rh-negative individuals to prevent the development of Rh isoimmunization, which could occur if the client is exposed to Rh-positive blood. In the case of an ectopic pregnancy, there may be a possibility of fetal blood mixing with the mother's bloodstream, which could lead to sensitization in an Rh-negative individual.
Choice D rationale: The desire to conceive again does not dictate the need for RhoGAM. It is solely based on the client's Rh factor status and the potential for sensitization during the ectopic pregnancy.

A. Ventricular septal defect B. Cesarean birth C. Small for gestational age D. Maternal history of asthma

Correct Answer is D

Explanation

Choice A rationale: Ventricular septal defect (VSD) is a congenital heart defect and is not directly related to respiratory distress syndrome or respiratory acidosis.
Choice B rationale: Cesarean birth, while it can have other implications, is not a direct risk factor for respiratory distress syndrome or respiratory acidosis. The mode of delivery does not directly impact the newborn's respiratory function.
Choice C rationale: While being small for gestational age can be associated with certain health challenges, it is not a direct risk factor for respiratory distress syndrome or respiratory acidosis. The baby's size does not determine its respiratory status.
Choice D rationale: Maternal history of asthma is a risk factor that can predispose the newborn to respiratory difficulties, including respiratory distress syndrome (RDS) and respiratory acidosis. Infants born to mothers with asthma may have a higher likelihood of developing respiratory problems due to potential genetic factors and exposure to environmental triggers during pregnancy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the immediate postoperative period following the removal of an ectopic pregnancy via salpingostomy. For which of the following indications should the nurse administer Rho(D) Immune globulin?

Correct Answer is C

Explanation

A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties?

Correct Answer is D

Explanation

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