The nurse is preparing for the care of a baby about to be delivered by caesarean section. What interventions will the nurse include in the plan of care? Select all that apply.

Obtain an arterial blood gas.

Ensure thermoregulation.

Administer oxygen as needed.

Insert an orogastric tube.

Keep the head in a sniffing position.

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: Obtaining an arterial blood gas is not typically a routine intervention immediately following a caesarean section. Arterial blood gas measurements are usually performed if there is a specific indication or concern about the baby's respiratory status or acid-base balance. Routine care focuses on stabilizing and assessing the baby rather than performing invasive procedures unless clinically indicated.

Choice B reason: Ensuring thermoregulation is a crucial intervention for newborns, especially those delivered by caesarean section. Maintaining an appropriate body temperature is essential to prevent hypothermia, which can lead to complications such as metabolic disturbances and respiratory issues. The nurse should use measures like pre-warmed blankets and radiant warmers to keep the baby warm and stable.

Choice C reason: Administering oxygen as needed is an important intervention to ensure the baby's oxygenation and respiratory stability. Newborns delivered by caesarean section may have transient respiratory difficulties due to the lack of the natural squeeze through the birth canal, which helps clear the lungs of fluid. Monitoring the baby's respiratory status and providing supplemental oxygen if necessary is vital for their well-being.

Choice D reason: Inserting an orogastric tube is not a standard routine intervention immediately after a caesarean section unless there is a specific indication, such as if the baby has difficulty feeding, significant respiratory distress, or gastrointestinal issues. Routine care focuses on more immediate stabilization measures unless clinical signs suggest the need for an orogastric tube.

Choice E reason: Keeping the head in a sniffing position is important for maintaining an open airway and ensuring effective ventilation. The sniffing position aligns the airway and promotes optimal breathing. This position is particularly useful for newborns who may have respiratory difficulties or require resuscitation efforts, ensuring that their airway remains patent and clear.

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Correct Answer is A

Explanation

Choice A reason: Warming the stethoscope before use prevents heat loss through conduction. Conduction is the transfer of heat from the infant's body to a cooler surface or object that comes in direct contact with them. By warming the stethoscope, the nurse ensures that the infant does not lose heat to the cold surface of the stethoscope, thereby helping to maintain the infant's body temperature.

Choice B reason: Moving the infant away from a drafty vent helps prevent heat loss through convection, not conduction. Convection is the transfer of heat through air currents, and keeping the infant away from drafts helps minimize this type of heat loss.

Choice C reason: Drying the infant with a towel prevents heat loss through evaporation. When a wet infant is dried, it helps reduce the loss of heat that occurs as moisture evaporates from the skin.

Choice D reason: Closing the doors to the isolate helps prevent heat loss through radiation. Radiation is the transfer of heat from the infant's body to cooler surrounding surfaces. By closing the doors, the nurse helps maintain a warm environment, reducing heat loss.

A. I haven't had a growth spurt yet, and all my friends are taller than me. B. My parents treat me like a baby sometimes. C. None of the kids at this school like me, and I don't like them either. D. There's a big project due by the end of the month, and I'm really stressed about it.

Correct Answer is C

Explanation

Choice A reason: Concerns about physical development, such as not having had a growth spurt yet, are common among adolescents. While this statement indicates some distress, it is generally considered a normal part of adolescent development and may not require immediate intervention.

Choice B reason: Feeling infantilized by parents is also a common issue among teenagers. This can be addressed through communication and support, but it is not typically an urgent matter.

Choice C reason: Statements about social isolation and feeling disliked by peers can be indicative of significant emotional distress or even depression. This statement warrants immediate attention to assess the adolescent's mental health and provide necessary support or intervention.

Choice D reason: Stress related to academic pressures, such as a big project, is common among students. While it is important to address stress management, it does not typically indicate an immediate risk to the student's well-being.

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