A nurse is caring for a client who had a post-term delivery and notes that the amniotic fluid was stained with meconium.

Which of the following actions should the nurse take first?

Suction the infant’s mouth and nose with a bulb syringe.

Assess the infant’s heart rate and respiratory effort.

Dry and stimulate the infant with a warm towel.

Clamp and cut the umbilical cord.

Answer and Explanation

The Correct Answer is B

This is because the infant born through meconium-stained amniotic fluid (MSAF) may have meconium aspiration syndrome (MAS), which is a condition that causes respiratory distress due to the inhalation of meconium into the lungs. The priority action for the nurse is to evaluate the infant’s breathing and circulation and initiate resuscitation if needed.

Choice A is wrong because suctioning the infant’s mouth and nose with a bulb syringe is not recommended unless the infant has obvious meconium in the airway and is not vigorous. Suctioning may cause bradycardia, hypoxia, or airway trauma.

Choice C is wrong because drying and stimulating the infant with a warm towel is part of the initial steps of resuscitation, but it should be done after assessing the infant’s heart rate and respiratory effort. Drying and stimulating may also increase the risk of meconium aspiration if the infant gasps.

Choice D is wrong because clamping and cutting the umbilical cord is not a priority action for an infant with possible MAS. The cord should be clamped and cut after ensuring that the infant is stable and has adequate oxygenation.

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Correct Answer is B

Explanation

Loose, peeling skin without lanugo or vernix is a symptom of post-term infants who have intrauterine growth restriction (IUGR).Post-term infants are born after 42 weeks of gestation and may have reduced placental function, resulting in less nutrition and oxygen for the fetus.This can cause them to have low birth weight, decreased subcutaneous fat and muscle mass, and dry skin.

Choice A is wrong because a large head in proportion to body size is not a sign of IUGR.It may indicate a congenital anomaly or a chromosomal disorder.

Choice C is wrong because increased subcutaneous fat and muscle mass are not signs of IUGR.They are signs of normal fetal growth and development.

Choice D is wrong because hypertonia and hyperreflexia are not signs of IUGR.They may indicate a neurological problem or a perinatal asphyxia (lack of oxygen during birth).

A. 0.9% sodium chloride B. Lactated Ringer’s C. Dextrose 10% in water D. Dextrose 5% in water.

Correct Answer is C

Explanation

Dextrose 10% in water.This is because parenteral nutrition (PN) is a mixture of nutrients that is given through a central venous catheter (CVC) that goes directly to the heart.PN contains high concentrations of nutrition and calories, and if the PN bag is empty, it needs to be replaced with a solution that has a similar osmolarity to prevent complications such as hypoglycemia (low blood sugar) or phlebitis (inflammation of the vein).Dextrose 10% in water has an osmolarity of about 500 mOsm/L, which is close to the osmolarity of PN solutions.

Choice A is wrong because 0.9% sodium chloride has an osmolarity of about 300 mOsm/L, which is lower than PN solutions and can cause fluid overload and electrolyte imbalance.

Choice B is wrong because lactated Ringer’s has an osmolarity of about 275 mOsm/L, which is also lower than PN solutions and can cause similar problems as 0.9% sodium chloride.

Choice D is wrong because dextrose 5% in water has an osmolarity of about 250 mOsm/L, which is much lower than PN solutions and can cause rapid drop in blood sugar and vein irritation.

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A nurse is caring for a client who had a post-term delivery and notes that the amniotic fluid was stained with meconium. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a post-term infant who was born with intrauterine growth restriction (IUGR). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC). The current PN bag is empty, and a new PN bag is not available at this time. Which of the following solutions should the nurse infuse until a new PN bag is available?

Correct Answer is C

Explanation

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A nurse is caring for a client who had a post-term delivery and notes that the amniotic fluid was stained with meconium.

Which of the following actions should the nurse take first?