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
Explanation
Choice A rationale
While weight gain is crucial during pregnancy, a blanket statement of 2 pounds per week is not universally appropriate. The recommended rate of weight gain varies based on the client's pre-pregnancy BMI and the trimester. Excessive or insufficient weight gain can lead to adverse maternal and fetal outcomes, including macrosomia or intrauterine growth restriction, highlighting the need for individualized nutritional guidance rather than a fixed weekly gain.
Choice B rationale
Dieting during pregnancy, especially restrictive calorie intake, can significantly compromise the nutrient supply to the developing fetus. Fetal growth and organogenesis are highly dependent on adequate maternal nutritional stores and daily nutrient intake. Inadequate nutrition can lead to low birth weight, premature birth, and long-term health complications for the infant, emphasizing the dangers of unguided dietary restrictions.
Choice C rationale
A dietitian possesses specialized knowledge in medical nutrition therapy and can provide personalized recommendations based on the adolescent's specific nutritional needs, gestational age, and pre-pregnancy weight. This collaborative approach ensures optimal maternal and fetal health by addressing any deficiencies, managing appropriate weight gain, and promoting healthy eating habits throughout the pregnancy, which is crucial for adolescent development and pregnancy outcomes.
Choice D rationale
The caloric needs of a pregnant adolescent increase in the second and third trimesters, but a fixed additional 700 calories per day may not be accurate for all individuals. Caloric requirements are dynamic and depend on pre-pregnancy weight, activity level, and the specific stage of gestation. Overestimation can lead to excessive weight gain, while underestimation can result in inadequate fetal growth, necessitating individualized assessment.
Correct Answer is A
Explanation
Choice A rationale
A client with an indwelling urinary catheter is at increased risk for falls due to several factors. The catheter tubing can create a tripping hazard, and the associated bag can restrict mobility. Furthermore, the presence of a catheter can lead to postural hypotension upon ambulation due to prolonged bedrest or fluid shifts, impairing balance and increasing fall risk.
Choice B rationale
A second-degree perineal laceration causes localized pain and discomfort, potentially leading to a cautious gait. While this can affect mobility, it does not inherently present the same level of tripping hazard or systemic physiological changes like orthostatic hypotension that are associated with an indwelling catheter, making the fall risk comparatively lower.
Choice C rationale
Saturating a perineal pad every 5 to 6 hours indicates a normal lochial flow. Excessive bleeding (saturating a pad in less than an hour) would be a significant risk factor for hypovolemia and subsequent orthostatic hypotension, thus increasing fall risk. Normal flow, however, does not directly contribute to an increased fall risk.
Choice D rationale
Breast engorgement causes discomfort and fullness in the breasts, which can limit arm movement and potentially interfere with comfortable positioning. While uncomfortable, breast engorgement itself does not typically lead to systemic physiological changes like orthostatic hypotension or create physical impediments that directly increase the risk of a fall.
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