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 B
Explanation
Choice A rationale
Diet cola, although refreshing, contains caffeine which can contribute to dehydration. For adolescents with sickle cell anemia, hydration is crucial to prevent sickle cell crises. Moreover, sodas generally offer no nutritional benefits.
Choice B rationale
Lemonade is a better choice as it is hydrating and provides fluids without caffeine. Proper hydration is vital for sickle cell patients to maintain blood volume and prevent the sickling of red blood cells. Additionally, lemonade can supply essential electrolytes.
Choice C rationale
Ice tea, similar to diet cola, contains caffeine which can exacerbate dehydration. Hydration is key for individuals with sickle cell anemia to avoid complications and maintain adequate blood flow.
Choice D rationale
Milkshake, while providing hydration, is high in fat and sugar, which can be counterproductive. It also lacks the electrolytes present in lemonade which are beneficial for maintaining fluid balance in the body.
Correct Answer is C
Explanation
Choice A rationale
While bleeding tendencies can be a concern in newborns, especially if there are clotting disorders, it is not the immediate priority in the first minutes after birth. Immediate interventions focus on establishing effective respirations and ensuring adequate oxygenation.
Choice B rationale
Fluid balance is important for newborns, particularly in the context of hydration and potential complications like hypovolemia. However, the most immediate concern after birth is ensuring the newborn can breathe adequately to deliver oxygen to the body's tissues.
Choice C rationale
Heat loss is a critical issue for newborns, as they are at high risk for hypothermia due to their large surface area relative to body weight and limited ability to generate heat. Preventing heat loss helps to stabilize the newborn's temperature and supports overall physiological stability, including respiratory function.
Choice D rationale
Hypoglycemia can be a concern in newborns, particularly those who are small for gestational age or have other risk factors. However, the most immediate concern in the first minutes after birth is ensuring adequate breathing to support oxygenation and prevent complications related to hypoxia. .
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