A nurse is caring for a client who has just delivered a newborn.
The nurse notices secretions bubbling out of the newborn’s nose and mouth. Which of the following actions should the nurse prioritize?
Turn the newborn on his side.
Suction the mouth with a bulb syringe.
Suction the nose with a bulb syringe.
Use a suction catheter with low negative pressure.
The Correct Answer is B
Choice A rationale
Turning the newborn on his side is a good practice to prevent aspiration, but it is not the first action to take. The newborn’s airway must be clear first to ensure proper breathing.
Choice B rationale
Suctioning the mouth with a bulb syringe is the priority action when a newborn has secretions bubbling out of the nose and mouth. This action helps clear the airway and allows the newborn to breathe more easily.
Choice C rationale
Suctioning the nose with a bulb syringe is also important, but the mouth should be suctioned first. This is because the newborn could aspirate oral secretions during inhalation if the mouth is not suctioned first.
Choice D rationale
Using a suction catheter with low negative pressure is not the first action to take. A bulb syringe is usually sufficient to clear the newborn’s airway of secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Drying the infant off and covering the head is important to prevent heat loss, but it is not the first action to be taken. The newborn’s body temperature can drop rapidly because of the evaporation of amniotic fluid, so drying the infant is a priority, but not the first one.
Choice B rationale
Stimulating the infant to cry is important as it helps to clear the lungs of amniotic fluid and promotes the expansion of the lungs for effective oxygenation. However, this is not the first action to be taken. The first action is to clear the respiratory tract.
Choice C rationale
Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly. This is done by suctioning the mouth first and then the nose to prevent aspiration of mucus or amniotic fluid, which can lead to respiratory distress.
Choice D rationale
Cutting the umbilical cord is done after the newborn’s respiratory status is stable. It is not the first action to be taken. The umbilical cord is usually clamped and cut by the healthcare provider after it has stopped pulsating, or after the newborn has started to breathe on their own.
Correct Answer is D
Explanation
The correct answer is choiced. Slightly above the umbilicus.
Choice A rationale:
At 22 weeks of gestation, the fundus is not typically 5 cm above the umbilicus. This measurement would be more consistent with a later stage of pregnancy, around 28 weeks.
Choice B rationale:
The fundus being slightly below the umbilicus is more consistent with an earlier stage of pregnancy, around 20 weeks. At 22 weeks, the fundus should be higher.
Choice C rationale:
The fundus being 3 cm below the umbilicus is also indicative of an earlier stage of pregnancy, not 22 weeks. This would be expected around 18-20 weeks.
Choice D rationale:
At 22 weeks of gestation, the fundus is typically located slightly above the umbilicus.This corresponds with the general rule that the fundal height in centimeters should match the number of weeks of pregnancy, give or take 2 cm.
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