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?
Determine if the newborn's mouth and nose require bulb suctioning.
Initiate skin-to-skin contact between parent and newborn.
Place the newborn under a radiant warmer.
Provide tactile stimulation for the newborn.
The Correct Answer is A
Choice A rationale
Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.
Choice B rationale
While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.
Choice C rationale
Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.
Choice D rationale
Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Rear-facing car seats are safer for infants and toddlers because they provide better support for their head, neck, and spine in the event of a collision. The American Academy of Pediatrics recommends keeping children in rear-facing seats until they are at least 2 years old or until they reach the highest weight or height allowed by the manufacturer.
Choice B rationale
A four-point harness is not sufficient for securing a baby in a car seat. A five-point harness, which includes two shoulder straps, two hip straps, and one crotch strap, provides more secure and effective restraint for infants.
Choice C rationale
The shoulder harness should be positioned in the slots at or below the baby's shoulders, not above, to ensure proper fit and restraint. Placing the harness above the shoulders can result in improper restraint and increased risk of injury in an accident.
Choice D rationale
The correct angle for a rear-facing car seat is typically 45 degrees, not 30 degrees. A 45-degree angle ensures the baby's airway remains open, preventing the head from falling forward and potentially causing breathing difficulties.
Correct Answer is A
Explanation
Choice A rationale
Checking fetal heart tones is the priority to assess the well-being of the fetus, especially in breech presentation and after the membranes have ruptured.
Choice B rationale
Preparing for a cesarean birth is important but follows the assessment of fetal heart tones and other immediate measures.
Choice C rationale
Checking the color, amount, and odor of the fluid is important, but ensuring fetal heart tones comes first to monitor any distress.
Choice D rationale
Performing a Nitrazine test to assess for rupture of membranes is redundant once the client reports her water has broken.
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