A nurse is caring for a client who has just delivered a newborn.
The nurse notices secretions bubbling out of the newborn’s nose and mouth. Which of the following actions should the nurse prioritize?
Turn the newborn on his side.
Suction the mouth with a bulb syringe.
Suction the nose with a bulb syringe.
Use a suction catheter with low negative pressure.
The Correct Answer is B
Choice A rationale
Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.
Choice B rationale
Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.
Choice C rationale
Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.
Choice D rationale
Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Covering the cord with the diaper can create a moist environment that promotes bacterial growth and delays healing.
Choice B rationale
Washing the cord daily with mild soap and water is not recommended. It’s better to keep the cord dry and clean.
Choice C rationale
Applying petroleum jelly to the cord stump is not advised. It can create a moist environment that can delay the drying and falling off of the stump.
Choice D rationale
Giving a sponge bath until the cord stump falls off is the correct instruction. This prevents the stump from getting wet, which can delay healing and increase the risk of infection.
Correct Answer is A
Explanation
Choice A rationale
Postpartum hemorrhage is a serious condition characterized by heavy bleeding after childbirth. In the scenario described, the nurse’s notes indicate that the client’s fundus is boggy and located 1 cm above the umbilicus, which becomes firm with massage. This could be a sign of uterine atony, a leading cause of postpartum hemorrhage. Additionally, the client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10, and the perineal pad shows a moderate amount of lochia rubra. These are all signs that could indicate a postpartum hemorrhage.
Choice B rationale
While infection is a possible postpartum complication, the symptoms provided do not strongly indicate an infection. Symptoms of a postpartum infection typically include soreness, tenderness, or swelling of the belly or abdomen, chills, pain while urinating or during sex, abnormal vaginal discharge that has a bad smell or blood in it, and a general feeling of discomfort or unwellness.
Choice C rationale
Thrombophlebitis is a condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow. It commonly occurs in the legs but can occur elsewhere in the body. The symptoms include swelling of the affected area, redness of the affected area, tenderness of the affected area, warmth around the affected area, and pain. However, the symptoms provided do not strongly indicate thrombophlebitis.
Choice D rationale
Pulmonary embolism is a serious condition that occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung. Symptoms can include shortness of breath or chest pain. However, the symptoms provided do not strongly indicate a pulmonary embolism.
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