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.

Answer and Explanation

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 A

Explanation

Choice A rationale
Given the frequency and duration of the contractions, along with the maternal and fetal vital signs, it is important to notify the healthcare provider immediately. These could be signs of labor progression and the healthcare provider can provide further instructions based on the clinical situation.
Choice B rationale
While managing pain is important, the priority in this situation is to communicate with the healthcare provider due to the frequency of contractions and the vital signs.
Choice C rationale

Having the patient void is not the priority in this situation. While a full bladder can affect labor progression, the frequency of contractions and the vital signs take precedence.
Choice D rationale
Positioning the patient with one hip elevated is not the priority in this situation. This position is often used to alleviate supine hypotensive syndrome, but the patient’s blood pressure is not indicating this condition.

A. Insert an indwelling urinary catheter. B. Administer oxytocin by continuous IV infusion. C. Massage the client’s fundus to promote contractions. D. Tilt the client onto her right side with her legs elevated to at least 30 degrees

Correct Answer is C

Explanation

Choice A rationale
Inserting an indwelling urinary catheter is not the immediate next step. While it may be necessary in some cases, the priority is to address the client’s excessive bleeding, which is a sign of postpartum hemorrhage.
Choice B rationale
Administering oxytocin by continuous IV infusion is a common intervention for postpartum hemorrhage. However, it is not the immediate next step. The nurse should first attempt to massage the client’s fundus to promote contractions and control bleeding.
Choice C rationale
Massaging the client’s fundus is the correct next step. The client’s symptoms indicate postpartum hemorrhage, a serious condition that can lead to shock and other complications. Fundal massage often helps the uterus contract and can stop the bleeding.
Choice D rationale
Tilting the client onto her right side with her legs elevated to at least 30 degrees is not the immediate next step. This position can help improve venous return but does not directly address the cause of the client’s symptoms.

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A nurse is assessing a newborn immediately after a scheduled cesarean delivery. Which of the following assessments should be the nurse’s priority?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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