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. Change the perineal pad of a client who just transferred from labor and delivery. B. Monitor vital signs during admission of a client who has gestational hypertension. C. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. D. Observe an area of redness on the breast of a client who is 1 day postpartum.

Correct Answer is C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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