The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?
Ineffective thermoregulation related to heat loss to the environment.
Altered nutrition less than body requirement related to limited formula intake.
Altered urinary elimination related to post-circumcision status.
Ineffective airway clearance related to mucus and water secretions.
The Correct Answer is D
Ineffective airway clearance related to mucus and water secretions. This is because newborns who are born via cesarean delivery are at risk for respiratory distress due to the lack of compression of the chest during birth. This can result in retained mucus and fluid in the lungs that can interfere with breathing and oxygenation. The nurse should prioritize clearing the airway and monitoring the respiratory status of the newborn.
Choice A is wrong because ineffective thermoregulation related to heat loss to the environment is not specific to cesarean delivery. All newborns are prone to heat loss due to their large surface area and thin skin. The nurse should maintain a warm and dry environment for the newborn and prevent exposure to cold surfaces.
Choice B is wrong because altered nutrition less than the body requirement related to limited formula intake is not specific to cesarean delivery. All newborns need adequate nutrition to support their growth and development. The nurse should monitor the intake and output of the newborn and assist with feeding as needed.
Choice C is wrong because altered urinary elimination related to post- circumcision status is not specific to cesarean delivery. Circumcision is an elective procedure that may or may not be performed on male newborns. The nurse should provide wound care and pain relief for the circumcised newborn and observe for signs of infection or bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.
Choice A is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.
Choice B is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.
Choice D is incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.
Correct Answer is D
Explanation
Sternal or chest retractions. This is because sternal or chest retractions are a sign of respiratory distress in newborns, which means they are having difficulty breathing. Chest retractions occur when the baby's chest pulls in with each breath, indicating that they are using extra muscles to breathe. This can be caused by various conditions that affect the lungs, such as respiratory distress syndrome (RDS), transient tachypnea of the newborn (TTN), meconium aspiration syndrome (MAS), pneumonia, or congenital heart defects.
Choice A is not correct because mucus draining from the nose is not a symptom of respiratory distress in newborns. It is normal for newborns to have some mucus in their nose and mouth after birth, which can be cleared by suctioning or wiping.
Mucus drainage does not interfere with breathing unless it is excessive or thick.
Choice B is not correct because cyanosis of the hands and feet is not a symptom of respiratory distress in newborns. It is normal for newborns to have bluish discoloration of their hands and feet, called acrocyanosis, for the first few days after birth. This is due to immature circulation and does not indicate a lack of oxygen. Cyanosis of the central parts of the body, such as the face, lips, and tongue, is more concerning and should be reported.
Choice C is not correct because irregular heart rate is not a symptom of respiratory distress in newborns. It is normal for newborns to have some variations in their heart rate, especially during sleep cycles. The normal heart rate range for newborns is 100 to 160 beats per minute. A heart rate that is too fast (tachycardia) or too slow (bradycardia) may indicate a problem with the heart or other organs³.
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