A nurse is caring for a newborn immediately following birth. The newborn has meconium-stained amniotic fluid.
Which of the following actions should the nurse take first?
Place the newborn under a radiant warmer.
Provide tactile stimulation for the newborn.
Determine if the newborn's mouth and nose require bulb suctioning.
Initiate skin-to-skin contact between parent and newborn.
The Correct Answer is C
Choice A rationale
Placing the newborn under a radiant warmer is crucial for thermoregulation, preventing cold stress, which can lead to increased metabolic rate and oxygen consumption. While important, assessing for potential airway compromise due to meconium aspiration takes immediate precedence over maintaining temperature, as respiratory status is critical for survival.
Choice B rationale
Providing tactile stimulation can encourage respiratory effort in a depressed newborn. However, in the presence of meconium-stained amniotic fluid, initial assessment of the airway and the need for suctioning must occur before stimulating the newborn to breathe deeper, which could potentially draw meconium further into the lungs.
Choice C rationale
When meconium-stained amniotic fluid is present, the primary concern is meconium aspiration syndrome. Determining if the mouth and nose require bulb suctioning is the first action to clear any meconium from the upper airway, preventing its aspiration into the lungs upon the newborn's first breaths, thereby mitigating respiratory distress.
Choice D rationale
Initiating skin-to-skin contact promotes maternal-newborn bonding and can stabilize the newborn's temperature and blood glucose. While beneficial, it is not the immediate priority when meconium is present. Airway management and respiratory stabilization must be ensured before initiating skin-to-skin contact to prevent complications from meconium aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Routine use of intubation equipment during a cesarean birth is not standard practice. Intubation is typically reserved for general anesthesia or respiratory compromise. Most cesarean births are performed under regional anesthesia, such as a spinal or epidural block, which allows the mother to remain awake and avoid the need for invasive airway management, minimizing associated risks.
Choice B rationale
Delay in initiating breastfeeding after a cesarean birth is not a universal or recommended practice. While there may be a slight delay due to recovery from anesthesia, early skin-to-skin contact and breastfeeding are encouraged as soon as the mother is stable and alert. This promotes maternal-infant bonding and successful lactation establishment, supporting newborn nutrition and development.
Choice C rationale
Early ambulation post-surgical procedure, including cesarean birth, is highly advantageous for preventing complications such as deep vein thrombosis and promoting recovery. Movement stimulates circulation, reduces gas accumulation in the intestines, and aids in the restoration of normal bowel function. This active recovery approach significantly improves patient outcomes and comfort.
Choice D rationale
Management of postpartum pain is a critical topic for clients undergoing a cesarean birth. Effective pain control is essential for the mother's comfort, ability to ambulate, and capacity to care for her newborn. Education should cover various pharmacological and non-pharmacological pain relief methods, including medication schedules, side effects, and when to request additional pain relief.
Choice E rationale
The need for an indwelling urinary catheter is a common aspect of cesarean birth. A catheter is typically inserted before the procedure to keep the bladder empty, reducing the risk of bladder injury during surgery and allowing for accurate monitoring of urine output post-operatively. It is usually removed within 12 to 24 hours postpartum as ambulation is initiated.
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Meconium stools are a normal physiological finding in a newborn during the first 24-48 hours of life. This thick, tarry, dark-green stool is composed of intestinal epithelial cells, amniotic fluid, bile, and water, reflecting fetal gastrointestinal tract development and function. Its presence indicates typical bowel activity.
Choice B rationale
Depressed fontanels indicate dehydration in a newborn. The fontanels are soft spots on a baby's head where the skull bones have not yet fused. When a baby is dehydrated, the fluid volume in the brain decreases, causing the fontanel to appear sunken below the normal contour of the skull, which necessitates immediate medical attention due to potential complications.
Choice C rationale
Rust-stained urine, also known as "brick dust" urine, in a newborn can indicate dehydration. This discoloration is caused by the excretion of urate crystals, which are a normal metabolic byproduct. However, in concentrated urine, these crystals become more visible, suggesting insufficient fluid intake and requiring further assessment to prevent significant dehydration.
Choice D rationale
Overlapping suture lines, also known as molding, are a common and expected finding in newborns, especially after vaginal delivery. This temporary reshaping of the fetal skull allows it to pass more easily through the birth canal and typically resolves spontaneously within a few days as the brain grows and fills the cranial cavity.
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