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 A
Explanation
Choice A rationale: The umbilical cord contains three blood vessels: two arteries and one vein. The two arteries carry deoxygenated blood and waste products from the fetus back to the placenta, while the one vein carries oxygenated blood and nutrients from the placenta to the fetus.
Choice B rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins. It contains two arteries and one vein.
Choice C rationale: This option is incorrect because the umbilical cord in a newborn does not have two veins and one artery. It contains two arteries and one vein.
Choice D Rationale: This option is incorrect because the umbilical cord in a newborn does not have only one artery and one vein. It contains two arteries and one vein.
Correct Answer is B
Explanation
Choice A rationale:
Newborns who are small for gestational age (SGA) are not at risk of having decreased circulating red blood cells (RBCs).
Choice B rationale:
Blood glucose instability is a common finding in SGA newborns.
Choice C rationale:
Retinopathy is not typically associated with being small for gestational age in newborns.
Choice D rationale:
A well-rounded abdomen is not specifically associated with being small for gestational age. SGA newborns often have a smaller body size compared to their gestational age, and their abdomen may appear proportionally smaller.
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