A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?
Place the newborn in the Trendelenburg position.
Administer saline drops into the newborn's nares.
Suction the newborn's mouth with a bulb syringe.
Perform deep suctioning of the newborn's trachea with an endotracheal tube.
The Correct Answer is C
Choice A rationale: Placing the newborn in the Trendelenburg position (head down, feet up) is not recommended in this situation and can potentially cause harm.
Choice B rationale: While saline drops can help clear nasal congestion, the bubbling mucus is coming from the mouth and nose, and suctioning is more appropriate.
Choice C rationale: The bubbling mucus indicates the presence of mucus and amniotic fluid in the baby's airway, which could interfere with breathing. The first action should be to suction the newborn's mouth to clear the airway.
Choice D rationale: Performing deep suctioning with an endotracheal tube is an invasive procedure and is not necessary for clearing mucus from the newborn's mouth and nose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: During phototherapy, it is essential to maintain adequate hydration and nutrition for the newborn. Encouraging frequent breastfeeding helps provide the baby with essential nutrients and fluids, which can be lost due to increased stooling caused by phototherapy.
Choice B rationale: The use of lotion on the newborn's skin during phototherapy is not recommended, as it may interfere with the effectiveness of the light therapy. The skin needs to be exposed to the light for the treatment to work.
Choice C rationale: Monitoring the newborn's blood glucose level is not directly related to phototherapy. Blood glucose monitoring may be necessary for specific medical reasons, but it is not a standard intervention during phototherapy.
Choice D rationale: During phototherapy, the newborn is usually placed in a supine (face-up) position to ensure maximum exposure of the skin to the phototherapy lights. The prone position is not recommended during phototherapy as it may reduce the effectiveness of the treatment.
Correct Answer is A
Explanation
Choice A rationale: The correct term to document this finding is "Quickening." Quickening refers to the first perception of fetal movement by the pregnant woman, usually described as light fluttering or sensation of movement in the abdomen. It is an exciting milestone for pregnant women and often occurs around 18 to 20 weeks of gestation. It is a significant moment as it indicates the woman can feel the baby's movements, signifying the fetus's increasing activity and growth.
Choice B rationale: Ballottement is a physical examination technique used to assess the fetus's position and movement within the amniotic fluid during pregnancy. It involves a gentle tap on the mother's abdomen to feel the fetus bounce or float in the amniotic fluid.
Choice C rationale: Chloasma, also known as the "mask of pregnancy," refers to dark patches of skin that may appear on the face during pregnancy due to hormonal changes. It is not related to the sensation of fetal movement.
Choice D rationale: Lightening, also known as "engagement," is the process in late pregnancy when the baby's head descends into the pelvis, preparing for childbirth. It often occurs a few weeks before labor begins and can result in the mother feeling less pressure on her diaphragm, which may make breathing easier. It is not related to the perception of fetal movement described by the client.
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