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 ["A","E"]
Explanation
Choice A rationale
Fetal heart rate assessment is paramount before administering an opioid analgesic during labor. Opioids can cross the placental barrier and cause central nervous system depression in the fetus, potentially leading to decreased fetal heart rate variability or transient decelerations. Therefore, a baseline and ongoing fetal heart rate monitoring is essential to ensure fetal well-being.
Choice B rationale
Deep tendon reflexes are primarily assessed when administering magnesium sulfate for preeclampsia, not typically before opioid analgesics. Magnesium sulfate can cause central nervous system depression and affect neuromuscular transmission, necessitating regular monitoring of deep tendon reflexes to assess for signs of toxicity. Opioids do not directly affect reflex activity in the same manner.
Choice C rationale
Blood glucose levels are not a standard assessment before administering opioid analgesics during labor. Blood glucose monitoring is crucial for clients with diabetes or gestational diabetes, or those receiving intravenous dextrose, but it is not directly related to opioid administration and its immediate effects on the mother or fetus.
Choice D rationale
Blood pressure assessment is crucial before administering an opioid analgesic because these medications can cause maternal hypotension due to their vasodilatory effects. Hypotension can reduce placental perfusion, compromising fetal oxygenation. Establishing a baseline blood pressure and monitoring it closely after administration helps ensure maternal cardiovascular stability and fetal well-being.
Choice E rationale
Pain level assessment is fundamental before administering an opioid analgesic. The primary purpose of administering an opioid is to alleviate labor pain. A thorough assessment of the intensity, location, and character of pain guides the choice, dosage, and timing of the analgesic, ensuring effective pain management and patient comfort while minimizing unnecessary medication.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should identify that weeks of gestation and contraction pattern are findings that require follow-up.
Rationale for correct answers:
Weeks of gestation at 32 weeks indicate a preterm pregnancy (<37 weeks), making any contractions concerning for possible preterm labor. The contraction pattern of increasing frequency (from every 5 minutes to every 3 minutes), longer duration (30 to 60 seconds), and moderate intensity signifies active uterine activity that can precipitate cervical changes and preterm birth risk. These two parameters warrant close monitoring and intervention to prevent premature delivery.
Rationale for incorrect answers (Response 1 options):
Blood pressure is within normal limits (128/83 and 117/80 mm Hg), so hypertensive disorders like preeclampsia are not indicated here. Pain score remains low (2/10), which is mild and not a primary indicator for urgent intervention. Parity (G1P0) does not influence immediate risk assessment for this clinical presentation.
Rationale for incorrect answers (Response 2 options):
Fetal heart rate remains normal at 140/min with no decelerations, indicating fetal well-being at this time. Nitrazine test is negative, showing intact membranes, which reduces the risk of premature rupture of membranes. Temperature is normal at 37°C, ruling out infection as a cause of contractions. Therefore, these findings do not require urgent follow-up in this scenario.
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