Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.
The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.
Which action should the nurse implement next?
Give blow-by oxygen via cannula.
Start IV infusion in a scalp vein.
Assist neonatologist with intubation.
Provide positive pressure ventilation.
Provide positive pressure ventilation.
The Correct Answer is D
Choice A rationale
Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.
Choice B rationale
Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.
Choice C rationale
Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.
Choice D rationale
Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Group therapy can be beneficial for individuals with substance abuse issues as it provides support, reduces isolation, and promotes healthy coping mechanisms. However, it is not the primary intervention for ensuring the health of the baby in a pregnant client on methadone.
Choice B rationale
Discontinuing methadone abruptly is dangerous and can lead to withdrawal symptoms, which can harm both the mother and the fetus. It is important to continue methadone treatment under medical supervision to prevent complications.
Choice C rationale
Genetic testing protocols are important for identifying potential genetic disorders but do not directly address the immediate health needs of a baby born to a mother on methadone treatment.
Choice D rationale
Starting a prenatal care plan as soon as possible is crucial for monitoring the health and development of the fetus, managing the mother's methadone treatment, and providing necessary interventions to ensure the baby's well-being. It is the best approach to ensure a healthy pregnancy.
Correct Answer is A
Explanation
Choice A rationale
A sore throat, often due to Streptococcus pyogenes, is a significant precursor to acute rheumatic fever. The body’s immune response to the infection can attack its own tissues, leading to rheumatic heart disease if untreated.
Choice B rationale
Influenza is a viral infection and does not typically lead to acute rheumatic fever. While it can cause significant illness, its mechanism and sequelae are unrelated to those of rheumatic fever.
Choice C rationale
Chickenpox, caused by the varicella-zoster virus, presents with distinct symptoms like a vesicular rash and is not linked to rheumatic fever. It primarily affects the skin and nervous system, not the heart.
Choice D rationale
Mumps, a viral infection, mainly impacts the salivary glands and sometimes the pancreas and testes but is not associated with rheumatic fever. Its pathology differs from the immune-mediated damage seen in rheumatic fever.
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