A nurse is caring for a client who had a post-term delivery and notes that the amniotic fluid was stained with meconium.
Which of the following actions should the nurse take first?
Suction the infant’s mouth and nose with a bulb syringe.
Assess the infant’s heart rate and respiratory effort.
Dry and stimulate the infant with a warm towel.
Clamp and cut the umbilical cord.
The Correct Answer is B
This is because the infant born through meconium-stained amniotic fluid (MSAF) may have meconium aspiration syndrome (MAS), which is a condition that causes respiratory distress due to the inhalation of meconium into the lungs. The priority action for the nurse is to evaluate the infant’s breathing and circulation and initiate resuscitation if needed.
Choice A is wrong because suctioning the infant’s mouth and nose with a bulb syringe is not recommended unless the infant has obvious meconium in the airway and is not vigorous. Suctioning may cause bradycardia, hypoxia, or airway trauma.
Choice C is wrong because drying and stimulating the infant with a warm towel is part of the initial steps of resuscitation, but it should be done after assessing the infant’s heart rate and respiratory effort. Drying and stimulating may also increase the risk of meconium aspiration if the infant gasps.
Choice D is wrong because clamping and cutting the umbilical cord is not a priority action for an infant with possible MAS. The cord should be clamped and cut after ensuring that the infant is stable and has adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Loose, peeling skin without lanugo or vernix is a symptom of post-term infants who have intrauterine growth restriction (IUGR).Post-term infants are born after 42 weeks of gestation and may have reduced placental function, resulting in less nutrition and oxygen for the fetus.This can cause them to have low birth weight, decreased subcutaneous fat and muscle mass, and dry skin.
Choice A is wrong because a large head in proportion to body size is not a sign of IUGR.It may indicate a congenital anomaly or a chromosomal disorder.
Choice C is wrong because increased subcutaneous fat and muscle mass are not signs of IUGR.They are signs of normal fetal growth and development.
Choice D is wrong because hypertonia and hyperreflexia are not signs of IUGR.They may indicate a neurological problem or a perinatal asphyxia (lack of oxygen during birth).
Correct Answer is A
Explanation
Exchange transfusion (ET) is a procedure that involves removing the infant’s blood and replacing it with compatible donor blood to reduce the level of bilirubin and/or antibody-coated red blood cells.It is a high-risk intervention that can cause serious complications such as vascular accidents, cardiovascular compromise, and electrolyte and hematologic derangement.
Therefore, it is essential to obtain informed consent from the parent before performing ET.
Choice B is wrong because checking the newborn’s blood type and crossmatch is not the first action the nurse should take.
Although it is important to ensure compatibility between the donor and recipient blood, it is not as urgent as obtaining informed consent.
Choice C is wrong because inserting two umbilical catheters for blood withdrawal and infusion is not the first action the nurse should take.
Although it is necessary to establish vascular access for ET, it is not as crucial as obtaining informed consent.
Choice D is wrong because monitoring the newborn’s vital signs and oxygen saturation is not the first action the nurse should take.
Although it is vital to assess the newborn’s condition before, during, and after ET, it is not as imperative as obtaining informed consent.
Normal ranges for bilirubin levels vary depending on the gestational age and postnatal age of the newborn.The American Academy of Pediatrics (AAP) has published nomograms for initiating phototherapy and ET based on these factors.According to the AAP, ET should be considered when the bilirubin level exceeds 25 mg/dL (428 μmol/L) in term infants or 20 mg/dL (342 μmol/L) in preterm infants with risk factors for neurotoxicity.
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