A nurse is reviewing the assessment findings of a paediatric patient. Which finding will the nurse prioritize?

Choice A reason: Obtaining an arterial blood gas is not typically a routine intervention immediately following a caesarean section. Arterial blood gas measurements are usually performed if there is a specific indication or concern about the baby's respiratory status or acid-base balance. Routine care focuses on stabilizing and assessing the baby rather than performing invasive procedures unless clinically indicated.

Choice B reason: Ensuring thermoregulation is a crucial intervention for newborns, especially those delivered by caesarean section. Maintaining an appropriate body temperature is essential to prevent hypothermia, which can lead to complications such as metabolic disturbances and respiratory issues. The nurse should use measures like pre-warmed blankets and radiant warmers to keep the baby warm and stable.

Choice C reason: Administering oxygen as needed is an important intervention to ensure the baby's oxygenation and respiratory stability. Newborns delivered by caesarean section may have transient respiratory difficulties due to the lack of the natural squeeze through the birth canal, which helps clear the lungs of fluid. Monitoring the baby's respiratory status and providing supplemental oxygen if necessary is vital for their well-being.

Choice D reason: Inserting an orogastric tube is not a standard routine intervention immediately after a caesarean section unless there is a specific indication, such as if the baby has difficulty feeding, significant respiratory distress, or gastrointestinal issues. Routine care focuses on more immediate stabilization measures unless clinical signs suggest the need for an orogastric tube.

Choice E reason: Keeping the head in a sniffing position is important for maintaining an open airway and ensuring effective ventilation. The sniffing position aligns the airway and promotes optimal breathing. This position is particularly useful for newborns who may have respiratory difficulties or require resuscitation efforts, ensuring that their airway remains patent and clear.

Choice A reason: Anencephaly is a severe neural tube defect where a major portion of the brain, skull, and scalp is missing. It does not present with a tuft of hair on the lumbosacral area.

Choice B reason: Spina bifida, specifically spina bifida occulta, is associated with a small tuft of hair on the lumbosacral area. This condition involves a defect in the spinal column where the bones do not close completely, but the spinal cord and nerves are usually not affected.

Choice C reason: Meningocele is a type of spina bifida where the protective membranes (meninges) protrude through an opening in the spine, forming a sac filled with cerebrospinal fluid. While it involves a spinal defect, it does not typically present with a tuft of hair.

Choice D reason: Myelomeningocele is the most severe form of spina bifida where the spinal cord and nerves protrude through an opening in the spine. This condition often results in more significant neurological deficits and is not specifically associated with a tuft of hair on the lumbosacral area.