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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Infection of the uterus typically presents with fever, foul-smelling lochia, and uterine tenderness, not bright red vaginal bleeding with a firm fundus. Firm fundus decreases the likelihood of retained products causing infection.
Choice B rationale
Uterine atony causes excessive vaginal bleeding due to the uterus's inability to contract effectively, but it doesn't apply here since the fundus is firm, indicating adequate uterine tone.
Choice C rationale
Perineal hematoma results from blood vessel damage during delivery. It causes a tense, painful mass and vaginal or perineal swelling, not steady, bright red bleeding with a firm fundus.
Choice D rationale
Lacerations of the genital tract result in bright red bleeding despite a firm fundus, as the bleeding originates from tears in the vaginal or perineal tissues rather than uterine atony.
Correct Answer is D
Explanation
Choice A rationale
A soft fundus indicates uterine atony, an abnormal finding requiring immediate intervention. This teaching would lead to improper patient monitoring of complications such as hemorrhage.
Choice B rationale
Clots as large as a golf ball are not considered normal and may signal uterine atony or retained placental fragments, which necessitate medical intervention for hemorrhage risk.
Choice C rationale
Decreased brownish-red lochia may reflect normal postpartum changes as it progresses to serosa and alba but is not typically an indicator of complications.
Choice D rationale
Increased lochia or a return to bright red bleeding signals potential complications like subinvolution or late postpartum hemorrhage, which demand prompt medical attention.
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