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 C
Explanation
Choice A rationale
Preparing for an emergency cesarean birth may be necessary in some cases of preeclampsia, particularly if there are signs of fetal distress or if the condition is not responding to treatment. However, in this scenario, the client’s symptoms are indicative of magnesium toxicity, not worsening preeclampsia.
Choice B rationale
Positioning the client in Trendelenburg (with the head lower than the feet) is not typically used in the management of preeclampsia or magnesium toxicity.
Choice C rationale
Discontinuing the medication infusion is the correct action in this scenario. The client’s symptoms (respiratory rate of 10/min and absent deep-tendon reflexes) are indicative of magnesium toxicity, a potential complication of magnesium sulfate therapy. Magnesium sulfate is used in the management of preeclampsia to prevent seizures, but it can cause toxicity if the levels become too high. If signs of toxicity occur, the infusion should be discontinued immediately.
Choice D rationale
Assessing maternal blood glucose may be necessary in some cases, particularly if the client has a history of diabetes. However, it is not the priority in this scenario, as the client’s symptoms are indicative of magnesium toxicity, not hyperglycemia.
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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