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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 ["B","C","D"]

Explanation

Choice A rationale

Hypertension is not a characteristic finding of hyperemesis gravidarum, which primarily affects fluid balance and nutritional status.

Choice B rationale

Dry mucous membranes are a sign of dehydration, commonly associated with hyperemesis gravidarum due to excessive vomiting.

Choice C rationale

Tachycardia can result from dehydration and electrolyte imbalances seen in hyperemesis gravidarum.

Choice D rationale

Poor skin turgor indicates dehydration, a common symptom of hyperemesis gravidarum.

Choice E rationale

Polyuria is not typical in hyperemesis gravidarum; the condition usually leads to dehydration, reducing urine output.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

The nurse should identify that the client is at the greatest risk for preterm birth due to:

Response 1: B) being higher than normal (fetal fibronectin: 0.09 mcg/mL is higher than the normal level of ≤ 0.05 mcg/mL).

Response 2: B) Nitrazine and ferning tests negative

Here's the

  • Fetal Fibronectin: Fetal fibronectin is a protein found between the amniotic sac and the uterine lining. Levels greater than 0.05 mcg/mL (like 0.09 mcg/mL) indicate an increased risk of preterm labor.
  • Nitrazine and Ferning Tests: Both tests being negative indicates that there is no rupture of membranes. Even though these tests are negative, the elevated fetal fibronectin level still indicates a risk for preterm birth.

So the completed sentence would be: The nurse should identify that the client is at the greatest risk for preterm birth due to fetal fibronectin being higher than normal and Nitrazine and ferning tests negative.

This combination of findings suggests that preterm labor may be imminent despite the lack of membrane rupture. The elevated fetal fibronectin is a strong indicator of risk.

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