A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe.
(Arrange the steps, placing them in the selected order of performance. Use all the steps.)
Compress the bulb syringe.
Place the bulb syringe in the newborn's mouth.
Assess the newborn for reflex bradycardia.
Use the bulb syringe to suction the newborns nose.
The Correct Answer is A, B, D, C
- Compressing the bulb syringe before placing it in the newborn's mouth or nose creates a vacuum that allows the suctioning of the mucus¹².
- Placing the bulb syringe in the newborn's mouth first helps clear the oral airway and prevent aspiration of mucus into the lungs¹². The nozzle of the bulb syringe should be gently inserted into the corner of the mouth, not the center, to avoid stimulating the gag reflex¹².
- Using the bulb syringe to suction the newborns nose helps clear the nasal airway and improve breathing¹². The nozzle of the bulb syringe should be gently inserted into one nostril at a time, and not too far, to avoid injuring the nasal mucosa¹².
- Assessing the newborn for reflex bradycardia helps monitor for any adverse effects of suctioning, such as a decrease in heart rate due to vagal stimulation¹³. Reflex bradycardia can cause hypoxia and acidosis in newborns, and may require oxygen administration or resuscitation³. The normal heart rate for a newborn is 120 to 160 beats per minute³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A newborn who is exposed to HIV perinatally should be bathed and cleansed of maternal secretions as soon as possible after birth to reduce the risk of HIV transmission through the skin or mucous membranes¹². The newborn should also receive antiretroviral prophylaxis within six hours of delivery, preferably within two hours¹². The type and duration of prophylaxis depend on the maternal and infant factors that influence the risk of HIV transmission, such as maternal viral load, antiretroviral therapy, mode of delivery, and infant gestational age¹²³. The newborn should also undergo HIV testing at birth, at 14 to 21 days of age, at one to two months of age, and at four to six months of age¹².
The other options are incorrect because:
b) Initiating contact precautions for the newborn is not necessary or recommended. Contact precautions are used to prevent the spread of infections that are transmited by direct or indirect contact with the patient or the patient's environment. HIV is not transmited by casual contact, and standard precautions are sufficient to prevent exposure to blood or body fluids that may contain HIV¹².
c) Administering intravenous antibiotics to the newborn is not indicated for HIV prevention. Antibiotics are used to treat bacterial infections, not viral infections like HIV. Antibiotics may be given to the newborn for other reasons, such as suspected sepsis or chorioamnionitis, but they do not affect the risk of HIV transmission¹².
d) Encouraging the mother to breastfeed her newborn is contraindicated for HIV prevention. Breastfeeding can transmit HIV from the mother to the infant through breast milk, especially if the mother has a high viral load, mastitis, cracked nipples, or oral lesions in the infant. In resource-limited settings where formula feeding may not be feasible or safe, breastfeeding with maternal or infant antiretroviral therapy may be considered, but in developed countries where safe alternatives are available, breastfeeding is not recommended for mothers with HIV infection¹².
Correct Answer is D
Explanation
A pudendal nerve block is a local anesthetic administered to block the pudendal nerve, which supplies sensation to the perineum and external genitalia. It is commonly used during childbirth to provide pain relief during the second stage of labor.
An adverse effect of a pudendal nerve block is a decreased ability to bear down, or a decreased ability to push effectively during labor. This is because the block affects the nerves responsible for the contraction of the pelvic floor muscles, which are necessary for effective pushing during delivery.
Option a) Uterine hyperstimulation is not an adverse effect of a pudendal nerve block. Uterine hyperstimulation refers to excessive contractions of the uterus, often caused by medications such as oxytocin. Pudendal nerve block does not directly affect uterine contractions.
Option b) Maternal hypertension is not an adverse effect of a pudendal nerve block. Hypertension refers to
high blood pressure, and it is not typically associated with a pudendal nerve block.
Option c) Fetal bradycardia is not a common adverse effect of a pudendal nerve block. Fetal bradycardia refers to a slow heart rate in the fetus. While fetal heart rate monitoring is important during labor, bradycardia is not typically associated with a pudendal nerve block.
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