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.
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Correct Answer is B
Explanation
Choice A rationale
Massaging the fundus is not necessary in this case. The fundus is firm, which indicates that the uterus is well contracted and there is no risk of postpartum hemorrhage. Massaging a well- contracted uterus can lead to uterine involution or even inversion.
Choice B rationale
Having the patient urinate is the correct action. A displaced fundus can be a sign of a full bladder. The bladder can push the uterus to the side and prevent it from contracting properly. By emptying the bladder, the uterus can return to its proper position and continue to contract to prevent bleeding.
Choice C rationale
Inserting a urinary catheter is not the first step. The nurse should first ask the patient to urinate. If the patient is unable to urinate, then a catheter may be necessary.
Choice D rationale
Administering an analgesic is not related to the position of the fundus. Pain management is important in postpartum care, but it is not the reason for a displaced fundus.
Correct Answer is ["B","E"]
Explanation
Choice A rationale
Abundant lanugo, which is fine hair, is not typically seen in postmature babies. It is more common in babies who are born prematurely.
Choice B rationale
A positive Moro reflex is a normal finding in newborns, including those who are postmature, indicating a healthy neurological response.
Choice C rationale
Vernix, a white creamy substance that protects the baby’s skin in the womb, is usually absent or very scant in postmature babies.
Choice D rationale
Short, soft fingernails are not a specific sign of postmaturity. Newborns’ fingernails can vary, and they often grow quickly after birth.
Choice E rationale
Cracked, peeling skin is commonly seen in postmature babies. Their skin can often appear dry and wrinkled.
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