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 C
Explanation
The baby is at risk for hemolytic jaundice if the mother has a different blood type that is incompatible with the baby’s blood type.This can cause the mother’s immune system to produce antibodies that attack the baby’s red blood cells, leading to hemolysis or excessive destruction of red blood cells.Hemolysis can cause bilirubin, a yellowish pigment, to accumulate in the baby’s blood, tissues, and fluids, causing jaundice.It can also cause anemia, a condition where the blood does not have enough healthy red blood cells.
Choice A is wrong because O positive is compatible with B negative.
O positive is the universal donor, meaning it can donate blood to any other blood type without causing a reaction.
Choice B is wrong because AB negative is compatible with B negative.
AB negative is the universal recipient, meaning it can receive blood from any other blood type without causing a reaction.
Choice D is wrong because A negative is incompatible with B negative.
A negative and B negative are different blood types that can cause a reaction if mixed together.
Correct Answer is D
Explanation
Phototherapy is a treatment that uses light to break down bilirubin in the blood and make it easier for the liver to eliminate it.
Phototherapy is effective when:
• The bilirubin levels decrease within 24 hours of treatment.
This means that the bilirubin is being cleared faster than it is being produced.
• The urine output and stool frequency increase during treatment.
This means that the bilirubin is being excreted through the kidneys and intestines.
• The skin color and muscle tone improve after treatment.
This means that the bilirubin is no longer causing jaundice or affecting the nervous system.
Statement A is wrong because it only describes one aspect of phototherapy effectiveness.
Statement B is wrong because it only describes another aspect of phototherapy effectiveness.
Statement C is wrong because it only describes the outcome of phototherapy effectiveness.
Statement D is correct because it includes all three aspects of phototherapy effectiveness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.