A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

Turn the newborn on his side.

Use a suction catheter with low negative pressure.

Suction the mouth with a bulb syringe.

Suction the nose with a bulb syringe

Answer and Explanation

The Correct Answer is C

A.   Turning the newborn on his side may be done after suctioning but is not the initial priority.
B.   Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C. Suctioning the mouth is a necessary step to ensure effective breathing.
D.   Suctioning  the nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.

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Correct Answer is D

Explanation

A. While the heart rate and respiratory rate are elevated, the blood pressure and temperature are within an acceptable range.
B. The heart rate and respiratory rate are within normal limits, and the blood pressure is elevated but not as concerning as other options.
C. The temperature and blood pressure are within normal limits, and while the heart rate is slightly elevated, it is not as concerning as other options.
D. The elevated heart rate, low blood pressure, and elevated temperature may indicate hypovolemic shock, which is of greatest concern given the history of significant estimated blood loss.

A. Place a hot pack to the perineum. B. Offer a warm sitz bath. C. Apply an ice pack to the affected area. D. Provide a squeeze bottle of antiseptic solution.

Correct Answer is C

Explanation

A. A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.

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A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

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