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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?

A.

Determine if the newborn's mouth and nose require bulb suctioning.

B.

Initiate skin-to-skin contact between parent and newborn.

C.

Place the newborn under a radiant warmer.

D.

Provide tactile stimulation for the newborn.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.

Choice B rationale

While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.

Choice C rationale

Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.

Choice D rationale

Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale

A hematoma presents as a localized collection of blood outside the blood vessels, causing a purplish discoloration and swelling, often resulting from trauma during delivery.

Choice B rationale

Retained placental fragments may cause postpartum hemorrhage and infection but would not present as a localized purplish swelling on the perineum.

Choice C rationale

A laceration would involve a tear in the tissue, causing bleeding and pain, but not necessarily a purplish discoloration with localized swelling unless associated with a hematoma.

Choice D rationale

Ecchymosis refers to bruising but is typically a more diffuse discoloration rather than a localized swelling and purplish area as seen with a hematoma.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Explanation

Preterm Labor

Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:

  • Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
  • Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
  • Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
  • Low backache: The client reports cramping and low back pain.

Preterm Prelabor Rupture of Membranes (PPROM)

PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:

  • Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.

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