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: 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.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale: Keeping the newborn in the center of a large crib is not a specific calming strategy and may not offer the comfort and security that the baby needs.
Choice B rationale: Taking the newborn for a ride in the car can be a calming strategy for some babies. The gentle motion and humming sound of the car can help soothe the baby.
Choice C rationale: Carrying the newborn in a front or backpack can provide comfort and security to the baby. The closeness to the parent's body and the rhythmic movement can help calm the baby.
Choice D rationale: Allowing the newborn to continue crying until she falls asleep is not a recommended strategy. Responding to the baby's cries and providing comfort and soothing is essential for the baby's emotional well-being.
Choice E rationale: Swaddling the newborn in a receiving blanket can help mimic the feeling of being in the womb, providing comfort and security to the baby. It can also prevent the startle reflex and promote better sleep.
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