A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes.

Exhibits

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.

The condition that poses the greatest risk to the newborn is

dropdown

due to

dropdown

.

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.

Essential

1. Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.

2. Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.

3. Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

1. Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

1. Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.

2. Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.