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 A
Explanation
Choice A rationale
Chlorhexidine is a broad-spectrum antiseptic effective against gram-positive and gram-negative bacteria. It is safe for patients allergic to betadine and reduces infection risks during catheter insertion.
Choice B rationale
Betadine, containing povidone-iodine, is contraindicated in patients with allergies to iodine. Using it could trigger allergic reactions, including anaphylaxis, compromising patient safety.
Choice C rationale
Sterile water lacks antiseptic properties and does not provide necessary antimicrobial activity to minimize infection risks, making it unsuitable for catheter insertion.
Choice D rationale
Alcohol wipes can cause tissue irritation and discomfort during catheter insertion. They are less effective against bacterial spores, reducing their efficacy for preventing infections in this context.
Correct Answer is C
Explanation
Choice A rationale
Hypoxia may contribute to tachypnea and distress, but it is unlikely the primary cause, as baseline fetal heart rate of 180 BPM indicates infection-related stress rather than isolated oxygen deprivation.
Choice B rationale
Respiratory distress syndrome predominantly affects preterm infants due to surfactant deficiency. At 37 weeks’ gestation, surfactant levels should be adequate, making this an unlikely cause of the newborn’s tachypnea and pallor.
Choice C rationale
Prolonged rupture of membranes increases the risk of neonatal sepsis. Signs such as tachypnea, pallor, and elevated fetal heart rate with marked variability suggest systemic infection requiring immediate evaluation and treatment.
Choice D rationale
Phrenic nerve injury typically causes diaphragmatic paralysis, leading to asymmetric chest movement and respiratory distress. However, it does not explain the systemic signs like pallor or elevated heart rate, making it an unlikely cause.
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