A 42-week gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is most critical at this time?
Ophthalmic assessment to check for conjunctival irritation.
Rectal temperature to assess for septic hyperthermia.
Bath to remove meconium-stained fluid from the skin.
Respiratory evaluation to monitor for respiratory distress.
The Correct Answer is D
Choice A rationale
While conjunctival irritation could occur from exposure to irritants, it is not a primary concern in this case. Respiratory complications take precedence due to the risk of aspiration from meconium-stained fluid.
Choice B rationale
Rectal temperature assessment for hyperthermia is important but not critical in the immediate scenario. Respiratory distress monitoring is more urgent due to the association with meconium aspiration syndrome.
Choice C rationale
Bathing to remove meconium-stained fluid minimizes infection risk. However, respiratory assessment is more critical due to the severe pulmonary complications associated with meconium aspiration.
Choice D rationale
Meconium-stained amniotic fluid increases the risk of aspiration, leading to respiratory distress. Early respiratory evaluation prevents hypoxia, pulmonary hypertension, or pneumonitis, which are serious complications in neonates.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Gastric problems later in life are not an immediate concern for infants with myelomeningocele, as they often arise secondary to neurological impairments or medications but do not pose immediate life-threatening risks at birth.
Choice B rationale
Respiratory depression in infants with myelomeningocele is rare unless coexisting brainstem anomalies or complications from anesthesia are present, which are typically managed during medical interventions.
Choice C rationale
Decreased cardiac output is not a primary risk in infants with myelomeningocele unless there is a coexisting cardiac anomaly, which is not a routine feature of this congenital condition.
Choice D rationale
Infection is a critical immediate risk due to the open neural tube defect in myelomeningocele, which exposes the spinal cord and meninges to environmental pathogens, increasing the risk of meningitis or systemic infection.
Correct Answer is C
Explanation
Choice A rationale
Respiratory depression is less common in myelomeningocele unless secondary to severe neurological anomalies. It is not the primary risk mediator in this congenital condition.
Choice B rationale
Decreased cardiac output is not directly associated with myelomeningocele. This condition primarily affects the spinal cord and surrounding tissues rather than cardiovascular function.
Choice C rationale
Infection risk is high due to exposed neural tissue, making it the most significant concern. Infection can lead to meningitis, sepsis, and neurological deterioration if not properly managed.
Choice D rationale
Neurological damage is inherent to myelomeningocele but does not act as an external risk mediator. The focus is on preventing additional risks like infections to improve outcomes.
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