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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

This is because cephalhematoma is a collection of blood under the scalp that does not cross the suture line. It is caused by trauma to the head during delivery, such as from vacuum extraction or forceps. It usually appears within a few hours or days after birth and resolves within weeks or months.

Choice B is not correct because nevus flammeus is a type of birthmark that is also known as port-wine stain. It is a flat, red, or purple patch of skin that can appear anywhere on the body, but often on the face. It is caused by abnormal blood vessels in the skin and does not go away over time³.

Choice C is not correct because the molding is the temporary change in the shape of the head due to pressure during delivery. It does not cause swelling or bruising and usually resolves within a few days.

Choice D is not correct because caput succedaneum is a type of swelling that affects the scalp and crosses the suture line. It is caused by fluid accumulation under the scalp due to pressure during delivery. It usually appears at birth and goes away within a few days.

A. Prevent infection of the umbilical cord B. Prevent infection of the eyes from vaginal bacteria C. Protect tear ducts from vaginal bacteria D. Protect the urethra from fecal material

Correct Answer is B

Explanation

Prevent infection of the eyes from vaginal bacteria. This is because some newborns can be exposed to bacteria such as gonorrhea or chlamydia during delivery, which can cause a serious eye infection called gonococcal ophthalmia neonatorum (GON). Applying an antibiotic ointment such as erythromycin or ilotycin can prevent GON and other less severe eye infections by killing the bacteria.

Choice A is not correct because the umbilical cord does not need antibiotic ointment to prevent infection. It should be kept clean and dry until it falls off naturally.

Choice C is not correct because the tear ducts are not affected by vaginal bacteria. They are small tubes that drain tears from the eyes to the nose.
Choice D is not correct because the urethra is not a common site of infection for newborns. The urethra is the tube that carries urine from the bladder to the outside of the body.

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The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should interpret this finding as which of the following?

Correct Answer is A

Explanation

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment.

Correct Answer is B

Explanation

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

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The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital?

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

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