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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?

A.

Respiratory distress

B.

Acrocyanosis.

C.

Accidental lacerations

D.

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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Related Questions

Correct Answer is C

Explanation

A. A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.

Correct Answer is B

Explanation

A. Moist lung sounds in this context are not indicative of an emergency situation requiring immediate notification of the pediatrician.
B. Moist lung sounds in a baby born by cesarean section are common and may be due to retained lung fluid, often resolving within the first 24 hours after birth. This is because the baby does not experience the same compression of the chest during delivery as a baby born vaginally, which helps to expel some of the fluid from the lungs.
C. Aspiration of surfactant is not a common or likely occurrence.
D. Moist lung sounds are not typically indicative of a pneumothorax, especially in the absence of other signs and symptoms.

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