A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse Include?
Insert the syringe tip before compressing the bulb.
Suction each of the nares before suctioning the mouth.
insert the tip of the syringe into the center of the newborn's mouth.
Stop suctioning when the newborn's cry sounds clear
The Correct Answer is D
The correct answer is D.
A. Insert the syringe tip before compressing the bulb: This is incorrect. The nurse should compress the bulb syringe first, then gently insert the tip into the newborn's nose, and then release the bulb to create suction for removing the mucus.
B. The client should suction the mouth first then the nares.
C. Insert the tip of the syringe into the center of the newborn's mouth: This is incorrect. The tip of the bulb syringe should be inserted into the side of the baby's mouth to avoid causing discomfort or stimulating the gag reflex.
D. When the newborn's cry may sound clear due to vocalization, but this may indicate that the airways are clear of secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.
B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.
C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.
D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.
Correct Answer is C
Explanation
The correct answer is C. Continuous contraction lasting 2 min.
A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.
B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.
C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.
A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.
D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.
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