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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“We need to monitor your kidney function because SLE can cause glomerulonephritis.” Glomerulonephritis is kidney inflammation caused by SLE that can damage the filtering units of the kidneys called glomeruli.SLE is an autoimmune disease that can affect various organs and tissues, including the kidneys.About half of the people with lupus experience kidney involvement, which can lead to kidney failure if not treated.
Therefore, it is important to monitor the kidney function of people with SLE.
Choice B is wrong because SLE does not cause hepatic necrosis, which is the death of liver cells.SLE can cause inflammation of the liver, but this is less common and less severe than kidney involvement.
Choice C is wrong because SLE does not cause hypothyroidism, which is a condition where the thyroid gland does not produce enough thyroid hormones.
SLE can affect the thyroid gland, but this is rare and usually does not affect the thyroid function.
Choice D is wrong because SLE does not cause diabetes mellitus, which is a condition where the body cannot regulate blood sugar levels.
SLE can cause inflammation of the pancreas, but this is uncommon and usually does not affect the insulin production.
Correct Answer is A
Explanation
The newborn’s skin color is pink.This indicates that the phototherapy is effective in lowering the serum bilirubin level by transforming it into water-soluble isomers that can be eliminated without liver conjugation.
A pink skin color also means that the newborn is not jaundiced, which is a sign of high bilirubin levels.
Choice B is wrong because clay-colored stools indicate a problem with the liver or bile ducts.Bile is needed to give stools their normal brown color, and if bile is absent or blocked, the stools may become pale or clay-colored.This could be a sign of a serious condition such as biliary atresia, which is a congenital defect that causes bile ducts to be absent or malformed.
Choice C is wrong because a bilirubin level of 12 mg/dL is still high for a newborn and may require further treatment.The American Academy of Pediatrics recommends phototherapy for newborns with bilirubin levels above 15 mg/dL at 25 to 48 hours of age, 18 mg/dL at 49 to 72 hours of age, and 20 mg/dL at more than 72 hours of age.However, these thresholds may vary depending on the gestational age, risk factors, and clinical condition of the newborn.
Choice D is wrong because dark yellow urine may indicate dehydration or concentrated urine, which can increase the risk of bilirubin toxicity.Newborns receiving phototherapy should be well hydrated and have frequent wet diapers to help eliminate bilirubin from the body.Normal urine color for a newborn is pale yellow or clear.
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