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 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.

A. Monitor weight. B. Monitor I&O. C. Monitor axillary temperature. D. Monitor blood glucose levels.

Correct Answer is D

Explanation

Choice A rationale

Monitoring weight is important for a newborn who is small for gestational age (SGA), but it is not the priority intervention. Weight can provide information about the newborn’s growth and development, but it does not address immediate physiological needs.
Choice B rationale
Monitoring I&O (Intake and Output) is crucial in assessing the newborn’s hydration status and kidney function. However, it is not the priority intervention for an SGA newborn.
Choice C rationale
Monitoring axillary temperature is important to maintain the newborn’s thermal regulation. However, it is not the priority intervention. Newborns, especially those who are SGA, are at risk for hypothermia due to their high body surface area to volume ratio and lack of subcutaneous fat.
Choice D rationale
Monitoring blood glucose levels is the priority intervention for an SGA newborn. SGA newborns are at risk for hypoglycemia because they have fewer glycogen stores. Hypoglycemia can lead to serious complications such as seizures, hence the need for close monitoring

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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

A nurse is caring for a patient who experienced a vaginal birth 3 hours ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which actions should the nurse take at this time?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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