A nurse is assessing a newborn immediately after a scheduled cesarean delivery. Which of the following assessments should be the nurse’s priority?
Accidental lacerations.
Acrocyanosis.
Respiratory distress.
Hypothermia.
The Correct Answer is C
Choice A rationale
While accidental lacerations can occur during a cesarean delivery, they are not typically the primary concern immediately after delivery.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and is not typically a priority concern immediately after delivery.
Choice C rationale
Respiratory distress is a priority concern in a newborn after a cesarean delivery. Newborns delivered by cesarean may have transient tachypnea of the newborn (TTN), a condition characterized by rapid breathing during the first few hours of life.
Choice D rationale
While hypothermia is a concern in newborns, it is not typically the immediate priority following a cesarean delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If the fundus is palpable to the right of the midline, it may indicate that the bladder is distended. A full bladder can displace the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with bladder distention. These contractions are a normal part of the postpartum period as the uterus returns to its pre- pregnancy size.
Choice C rationale
Having less than 2.5 cm of rubra lochia on a perineal pad does not indicate bladder distention. This is a normal finding in the postpartum period.
Choice D rationale
An increased thirst is not typically associated with bladder distention. It is a common symptom in the postpartum period due to fluid shifts and breastfeeding.
Correct Answer is C
Explanation
Choice A rationale
A probable sign of pregnancy includes objective signs observed by an examiner, such as changes in the pelvic organs, enlargement of the abdomen, and positive pregnancy test.
Choice B rationale
Possible signs of pregnancy are those that are subjective and reported by the patient, such as nausea, vomiting, and missed period. These signs could be due to other conditions.
Choice C rationale
Feeling the baby moving, also known as quickening, is a presumptive sign of pregnancy. These are changes felt by the woman herself and can be caused by other conditions.
Choice D rationale
Positive signs of pregnancy are those that are confirmed by the examiner and cannot be caused by any other condition. These include hearing the fetal heartbeat, visualizing the fetus, and feeling the baby move.
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