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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: This response dismisses the client's concerns and is not helpful or informative.
Choice B rationale: While some situations may warrant a repeat cesarean section, this response is not appropriate without knowing the client's specific medical history and the reason for the previous cesarean birth.
Choice C rationale: While there are indeed various factors that impact the possibility of VBAC, the nurse can still provide some general information and considerations to the client, especially regarding the type of uterine incision.
Choice D rationale: This option provides appropriate information to the client regarding VBAC. The type of uterine incision from the previous cesarean birth is a crucial factor in determining whether VBAC is safe and feasible. Clients with a low transverse uterine incision generally have a higher likelihood of being candidates for VBAC.
Correct Answer is B
Explanation
Choice A rationale: While it's true that newborns can have irregular breathing patterns, this response may come across as dismissive and not addressing the client's concerns.
Choice B rationale: The nurse should respond by actively listening to the client's concerns and offering to assess the newborn's breathing while they are feeding. Newborns can have irregular breathing patterns, including periods of rapid breathing (tachypnea) and pauses in breathing (periodic breathing). These patterns are generally normal and related to the baby's immature respiratory system adjusting to life outside the womb.
Choice C rationale: This response does not address the client's concern about the baby's breathing and instead focuses on the client's potential as a mother.
Choice D rationale: This response may minimize the client's concerns and does not address the baby's breathing issue. It's essential to acknowledge and assess the newborn's breathing pattern to ensure it is within the normal range.
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