A nurse is reinforcing teaching with the mother of a newborn about the proper use of a bulb syringe for suctioning.
Which of the following instructions should the nurse include in the teaching?
Lubricate the bulb with sterile water prior to use.
Depress the bulb prior to insertion.
Place the bulb in the center of the newborn's mouth.
Suction the newborn's nose first, then the mouth.
The Correct Answer is B
Choice A rationale
Lubricating the bulb syringe with sterile water is unnecessary and could introduce fluid into the newborn's airway or mouth, potentially causing aspiration. The bulb syringe is designed for mechanical suctioning and does not require lubrication for effective and safe use in clearing secretions from the newborn's mouth and nose.
Choice B rationale
Depressing the bulb prior to insertion creates a negative pressure or vacuum within the syringe. This action allows for effective suctioning of secretions when the bulb is released after insertion into the newborn's mouth or nose, ensuring that mucus is drawn into the syringe for removal.
Choice C rationale
Placing the bulb in the center of the newborn's mouth could stimulate the gag reflex, potentially causing vomiting or aspiration of secretions. The bulb syringe should be inserted into the side of the newborn's mouth, between the cheek and gums, to facilitate effective suctioning without triggering an adverse response.
Choice D rationale
Suctioning the newborn's nose first, then the mouth, is an incorrect sequence. The mouth should always be suctioned first to prevent the newborn from aspirating any oral secretions into the lungs if they gasp or inhale after nasal suctioning, ensuring a clear airway before nasal passages are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Auscultating bowel sounds is an important assessment, but it is not the first action for a newborn with neonatal abstinence syndrome. Respiratory compromise is a life-threatening complication that requires immediate assessment to ensure adequate oxygenation and ventilation, as respiratory depression can occur due to central nervous system effects of withdrawal.
Choice B rationale
Swaddling can provide comfort and reduce hyperirritability in a newborn with neonatal abstinence syndrome. While beneficial, it is a supportive intervention. Prioritizing physiological stability, specifically respiratory status, is essential before implementing comfort measures to address potentially life-threatening complications.
Choice C rationale
Determining the newborn's respiratory rate is the first action because respiratory depression or distress is a critical and potentially life-threatening symptom of neonatal abstinence syndrome. Accurate assessment of respiratory effort, rate (normal range is 30-60 breaths/minute), and presence of retractions or nasal flaring is paramount to ensure adequate oxygenation and guide immediate interventions.
Choice D rationale
Weighing a wet diaper assesses hydration and urinary output. While important for overall assessment, it is not the immediate priority for a newborn experiencing neonatal abstinence syndrome, as respiratory stability takes precedence due to the direct threat to life that respiratory compromise can pose in these vulnerable infants.
Correct Answer is C
Explanation
Choice A rationale
Hyperglycemia in gestational diabetes typically leads to increased urination, or polyuria, not decreased urination. Elevated blood glucose levels overwhelm the renal tubules' reabsorption capacity, leading to glucose spilling into the urine, which then draws water osmotically, increasing urine output.
Choice B rationale
Shallow respirations are not a direct manifestation of hyperglycemia in this context. While severe diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, can lead to Kussmaul respirations (deep, rapid breathing) due to metabolic acidosis, hyperglycemia alone typically does not cause shallow respirations.
Choice C rationale
Thirst, or polydipsia, is a classic manifestation of hyperglycemia. High blood glucose levels increase the osmolality of the blood, stimulating osmoreceptors in the hypothalamus, which then trigger the sensation of thirst as the body attempts to dilute the excess glucose and restore fluid balance.
Choice D rationale
While hunger (polyphagia) is a common symptom in uncontrolled type 1 diabetes due to cellular inability to utilize glucose, in gestational diabetes with hyperglycemia, hunger is not a predominant or consistent symptom. The body typically has sufficient insulin, but there is insulin resistance or insufficient production.
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