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 B
Explanation
Your baby can lose 5% of body weight during the first 3 days of life. This is a normal physiological process that happens as your baby adjusts to breastfeeding and expels excess fluids. Your baby should regain this weight by 10 to 14 days of age.
Choice A is incorrect because your baby does not need to feed constantly in the first week of life. Your baby should feed at least eight times in 24 hours but may have periods of cluster feeding where they feed more frequently for a few hours.
Choice C is incorrect because your baby should have more than 5 wet diapers per day after the fourth day of life. This is a sign that your baby is getting enough milk and is well-hydrated.
Choice D is incorrect because your baby should gain more than 0.25 oz (7 grams) per day after the fourth day of life. The average weight gain for a breastfed baby is about 0.5 to 1 oz (14 to 28 grams) per day in the first month.
Correct Answer is C
Explanation
Place the infant on the mother's abdomen after birth. This will help the infant maintain an adequate body temperature by providing skin-to-skin contact with the mother, which reduces heat loss and promotes bonding. Skin-to-skin contact also stimulates the baby's natural feeding cues and helps initiate breastfeeding.
Choice A is not correct because turning up the temperature in the birth room may not be enough to prevent heat loss from the infant, especially if they are wet or exposed to cold surfaces. It may also make the mother uncomfortable or dehydrated.
Choice B is not correct because bathing the infant immediately after birth may increase heat loss from evaporation and conduction. It may also interfere with the baby's natural protective coating (vernix) and microbiome. Bathing should be delayed until at least 24 hours after birth.
Choice D is not correct because wrapping the infant in a warm, dry blanket may not provide the same benefits as skin-to-skin contact with the mother. It may also prevent the baby from smelling and seeing the mother's breast, which are important cues for breastfeeding initiation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today