A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

Turn the newborn on his side.

Use a suction catheter with low negative pressure.

Suction the mouth with a bulb syringe.

Suction the nose with a bulb syringe

Answer and Explanation

The Correct Answer is C

A.   Turning the newborn on his side may be done after suctioning but is not the initial priority.
B.   Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C. Suctioning the mouth is a necessary step to ensure effective breathing.
D.   Suctioning  the nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.

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Correct Answer is B

Explanation

A. This is not appropriate for the taking-in stage, as the woman may not be ready to absorb new information or focus on self-care. She may need more verbal instruction and demonstration from the nurse.
B. The taking-in stage is a period of passive, dependent behavior in which the woman reviews her childbirth experience and adjusts to the new role of motherhood. She may need to talk about her labor and delivery repeatedly and seek reassurance from others. The nurse should listen attentively and validate her feelings.
C. This is more suitable for the taking-hold stage, which occurs after the taking-in stage. In this stage, the woman becomes more active and independent, and shows interest in learning how to care for herself and her baby.
D. This is also more appropriate for the taking-hold stage, when the woman develops confidence and competence in her maternal role. In the taking-in stage, she may be more focused on her own needs and rely on others to care for the baby.

A. Assess the client’s uterine fundus. B. Assist the client on a bedpan to urinate. C. Increase the client’s fluid intake. D. Prepare to administer oxytocic medication.

Correct Answer is A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

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A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

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Naxlex Comprehensive Predictor Exams

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