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
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.
Correct Answer is A
Explanation
Choice A rationale
A perineal hematoma is a collection of blood in the connective tissue beneath the skin, often caused by trauma during childbirth. The reported findings of increasing perineal pain, pressure, purplish discoloration, and swelling are classic signs. The purplish hue indicates extravasated blood, and the swelling reflects the accumulation of fluid, which can exert significant pressure on surrounding tissues, leading to severe discomfort and a palpable mass.
Choice B rationale
Retained placental fragments typically manifest as persistent or excessive postpartum bleeding, often bright red, and can lead to uterine subinvolution and infection. While pain might be present due to uterine contractions, it would not typically present as a localized, purplish, swollen area on the perineum. This finding is not consistent with the pathophysiology of retained placental fragments, which primarily affects the uterus.
Choice C rationale
A laceration is a tear in the soft tissues of the perineum or vagina, resulting in bright red bleeding, pain, and sometimes a visible opening. While pain is present, a laceration would not typically present with a 4 cm purplish discoloration and significant swelling without active, bright red bleeding from the tear site itself. The described findings are more indicative of internal bleeding and tissue accumulation rather than an open wound.
Choice D rationale
Ecchymosis is a bruise, characterized by superficial extravasation of blood into the skin or mucous membranes, resulting in a purplish discoloration. While the purplish discoloration is consistent, ecchymosis alone typically does not involve the significant palpable swelling and increasing pressure described. The extent of swelling and pressure points to a deeper collection of blood, distinguishing it from simple superficial bruising.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.