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 D
Explanation
A nonstress test (NST) is a common procedure used to assess the well-being of the fetus. During an NST, the fetal heart rate is monitored for a period of time to evaluate its response to fetal movement. In a normal NST, the fetal heart rate should show accelerations (temporary increases in heart rate) with fetal movement. Lack of accelerations can indicate fetal compromise or a non-reactive test.
In the given scenario, the absence of accelerations for 20 minutes indicates a non-reactive NST. In such cases, further interventions may be required to stimulate the fetus and provoke a response. Vibroacoustic stimulation is a non-invasive method that involves using sound or vibration to stimulate the fetus and elicit a fetal heart rate acceleration. It can be performed by placing a device on the mother's abdomen and delivering a brief sound or vibration near the fetal head.
Option a) Placing the client in the Trendelenburg position is not appropriate in this situation. The Trendelenburg position involves placing the client's head lower than the feet, and it is not indicated for a non-reactive NST.
Option b) Conducting a vaginal exam is not necessary in this scenario. The non-reactive NST indicates a lack of fetal heart rate accelerations, and a vaginal exam would not provide additional information or help in this situation.
Option c) Collecting a specimen for an indirect Coombs test is unrelated to the non-reactive NST. An indirect Coombs test is used to detect antibodies in the mother's blood that could potentially cause hemolytic disease of the newborn. It is not indicated as a response to a non-reactive NST.
Correct Answer is C
Explanation
Phototherapy is a treatment method used to reduce high levels of bilirubin in the blood of a newborn with jaundice. During phototherapy, the newborn is exposed to special lights that help break down the bilirubin and allow it to be eliminated from the body. It is important to protect the newborn's eyes during phototherapy.
Option a) Giving the newborn 1 oz of glucose water every 4 hours is not necessary for phototherapy. The primary goal of phototherapy is to treat jaundice, and providing glucose water is not directly related to this treatment.
Option b)Applying a thin layer of lotion to the newborn's skin every 8 hours is not necessary during phototherapy. In fact, it is generally recommended to avoid applying lotions or oils to the skin during phototherapy as they can interfere with the effectiveness of the treatment.
Option c) Ensuring the newborn's eyes are closed beneath the shield is essential during phototherapy. The eyes are particularly sensitive to the light used in phototherapy, and exposure to the light can potentially damage the eyes. Therefore, the newborn's eyes should be protected with a shield or eye patches to prevent direct exposure to the light.
Option d) Dressing the newborn in a thin layer of clothing during therapy is appropriate. The newborn should be dressed in a way that allows as much of their skin as possible to be exposed to the phototherapy lights. This usually involves removing unnecessary clothing and covering the genital area with a diaper, while the rest of the body is exposed to the light.
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