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:
Newborns of diabetic mothers are at risk of developing hypoglycemia (low blood sugar) after birth, especially if they are large for gestational age like the newborn in this scenario.
Choice B rationale:
Hypercalcemia (high blood calcium levels) is not a typical concern in newborns of diabetic mothers, and it is not directly related to the baby's size.
Choice C rationale:
Decreased REC (Respiratory Exchange Capacity) is not a common issue in this scenario, and it is not related to the baby's size or the mother's diabetes.
Correct Answer is D
Explanation
Choice A rationale: Applying identification bands is an essential step in newborn care, but it is not the priority immediately after delivery. The nurse should first address the baby's physiological needs, such as drying and maintaining body temperature.
Choice B rationale: Assessing and documenting the Apgar score is important for evaluating the newborn's overall condition and response to delivery, but it is not the priority immediately after delivery.
Choice C rationale: Administering phytonadione (vitamin K) to prevent bleeding disorders in the newborn is essential, but it can be done after drying and stabilizing the baby's body temperature.
Choice D rationale: After ensuring a patent airway, the nurse's priority should be to dry the newborn. Drying the newborn is important for maintaining body temperature and preventing heat loss, especially during the immediate post-delivery period. Wet newborns can lose heat rapidly through evaporation, so drying the baby helps prevent hypothermia and stabilize the baby's body temperature.
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