A nurse is assessing a newborn immediately following a scheduled cesarean delivery.

Which of the following assessments is the nurse’s priority?

Respiratory distress

Acrocyanosis.

Accidental lacerations

Hypothermia

Answer and Explanation

The Correct Answer is A

A.   Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B.   Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D.   While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.

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Correct Answer is A

Explanation

A. The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B. The uterine fundus would be too high for this time frame.
C. The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D. The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.

A. “Look at how she looks as you when you speak. That’s a good sign.” B. “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.” C. “There is no need to worry about that. Most forms of hearing loss are not inherited.” D. “The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”

Correct Answer is B

Explanation

A. While visual attention to the speaker is a positive sign, routine hearing screenings provide a more accurate assessment of hearing.
B. Routine hearing screenings are conducted on newborns to identify hearing issues early, allowing for intervention if necessary.
C. While most forms of hearing loss may not be inherited, it's important to assess the newborn's hearing through appropriate screenings.
D. Startle reflex is not a reliable indicator of hearing ability, and routine screenings provide more accurate information.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a vaginal delivery 16 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is assessing a newborn immediately following a scheduled cesarean delivery.

Which of the following assessments is the nurse’s priority?