A nurse is caring for a newborn immediately following birth. The newborn has meconium-stained amniotic fluid.
Which of the following actions should the nurse take first?
Place the newborn under a radiant warmer.
Provide tactile stimulation for the newborn.
Determine if the newborn's mouth and nose require bulb suctioning.
Initiate skin-to-skin contact between parent and newborn.
The Correct Answer is C
Choice A rationale
Placing the newborn under a radiant warmer is crucial for thermoregulation, preventing cold stress, which can lead to increased metabolic rate and oxygen consumption. While important, assessing for potential airway compromise due to meconium aspiration takes immediate precedence over maintaining temperature, as respiratory status is critical for survival.
Choice B rationale
Providing tactile stimulation can encourage respiratory effort in a depressed newborn. However, in the presence of meconium-stained amniotic fluid, initial assessment of the airway and the need for suctioning must occur before stimulating the newborn to breathe deeper, which could potentially draw meconium further into the lungs.
Choice C rationale
When meconium-stained amniotic fluid is present, the primary concern is meconium aspiration syndrome. Determining if the mouth and nose require bulb suctioning is the first action to clear any meconium from the upper airway, preventing its aspiration into the lungs upon the newborn's first breaths, thereby mitigating respiratory distress.
Choice D rationale
Initiating skin-to-skin contact promotes maternal-newborn bonding and can stabilize the newborn's temperature and blood glucose. While beneficial, it is not the immediate priority when meconium is present. Airway management and respiratory stabilization must be ensured before initiating skin-to-skin contact to prevent complications from meconium aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
During labor, the body experiences physiological stress and an inflammatory response, leading to an increase in white blood cell count. This leukocytosis is a normal physiological adaptation to the physical demands of labor and tissue remodeling, not a decrease. A normal WBC count is typically 4,500-11,000 cells/µL, and it can rise to 15,000-20,000 cells/µL during labor.
Choice B rationale
Labor is an energy-intensive process that increases metabolic demands, leading to greater glucose utilization by uterine muscles and other tissues. This increased consumption of glucose can result in a decrease in blood glucose levels as the body expends energy to fuel contractions and other physiological activities. A normal blood glucose range is 70-100 mg/dL.
Choice C rationale
The pain and physiological stress of labor typically cause an increase in respiratory rate, not a decrease. The body tries to compensate for the increased metabolic demand and oxygen consumption by increasing ventilation. A decrease in respiratory rate would be an unexpected and potentially concerning finding, indicating respiratory depression. A normal respiratory rate is 12-20 breaths per minute.
Choice D rationale
While slight fluctuations can occur, a significant decrease in temperature is not an expected finding during labor. The metabolic activity and physical exertion of labor can slightly elevate body temperature, or it may remain stable. A decrease in temperature could indicate hypothermia or a systemic issue, which is not a normal physiological response to labor. A normal temperature is 36.5-37.5°C.
Correct Answer is B
Explanation
Choice A rationale
Holding the newborn during the initial visit can inadvertently convey a message of displacement to the older sibling. This is due to the older child's developing cognitive understanding of parental attention and resources. The immediate focus on the new baby might lead to feelings of jealousy or being replaced, potentially hindering positive sibling bonding.
Choice B rationale
Spending individual time with the older sibling reinforces their continued importance within the family structure. This dedicated attention helps mitigate feelings of neglect or competition, promoting a sense of security and love. It allows the older child to process the family change and feel valued, fostering a more positive acceptance of the newborn.
Choice C rationale
While involving the older sibling in purchasing a gift can be a positive step, it might not fully address the emotional and psychological adjustments required. The act itself is a superficial gesture and doesn't substitute for direct parental reassurance and quality time, which are crucial for true sibling acceptance and emotional well-being.
Choice D rationale
Postponing the introduction can create anxiety and resentment in the older sibling. Children often perceive delays as exclusion or secrecy, which can foster negative feelings towards the new baby. An early, supervised introduction, with parental guidance, allows for a more natural and integrated family adjustment.
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