A woman who underwent a primary cesarean birth for a breech presentation states that her neonate seems to have so much more mucus than her first baby. Concerned, she asks why this has happened.
What is the best response by the nurse?
There is no scientific reason for this occurrence; your baby will be fine in a few hours.
All babies are different so it is unwise to make comparisons between your first baby and your new baby.
Babies born by cesarean section do not have the benefit of having the mucus in their lungs removed by the pressure experienced in the birth canal.
The pain medication given during the surgery may have contributed to the mucus build up in the neonate after birth.
The Correct Answer is C
Choice A rationale
This is an unscientific and dismissive response. There is a clear physiological reason for increased neonatal mucus following a cesarean birth. During a normal vaginal delivery, the thoracic squeeze exerted by the birth canal helps physically expel lung fluid and mucus, aiding the transition to extrauterine respiration.
Choice B rationale
While individual differences exist, this response fails to address the specific pathophysiology associated with the increased mucus observed in cesarean-born neonates. The lack of vaginal compression is a known factor that significantly impacts the clearance of fetal lung fluid and mucus, leading to transient tachypnea.
Choice C rationale
The lack of the "thoracic squeeze" during a cesarean birth means less fetal lung fluid and mucus are mechanically cleared compared to a vaginal birth. This remaining fluid can manifest as increased mucus-like secretions and often leads to conditions like Transient Tachypnea of the Newborn (TTN) as the lungs absorb the remaining fluid.
Choice D rationale
Pain medications like opioids, which may cross the placenta, primarily cause neonatal respiratory depression by acting on the central nervous system's respiratory centers, not by directly causing a physical build-up or inadequate clearance of mucus in the respiratory tract. Mucus clearance is a mechanical process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While documentation of lochia amount and type is a necessary component of ongoing assessment, it is not the priority over directly assessing the physiological state of the uterus in the fourth stage of labor. Lochia is the normal discharge of blood, mucus, and uterine tissue post-delivery. A soaked pad (approximately 75 mL) of lochia rubra within a short period suggests a need to check the uterine tone immediately, as uterine atony is the primary cause of early postpartum hemorrhage.
Choice B rationale
Although a distended bladder can displace the uterus and impair its contractility, causing excessive bleeding, the direct physical assessment of the fundus (Choice D) is the priority. Emptying the bladder is an important intervention if the uterus is found to be boggy and displaced; however, the nurse must first confirm the status of the uterine fundus to rule out or quickly address uterine atony, which is a life-threatening complication.
Choice C rationale
Measuring hemoglobin and hematocrit provides valuable retrospective data about the client's blood loss status, but it is not an immediate action that will prevent further blood loss. The priority is to implement a direct, immediate intervention to stop or reduce hemorrhage. The lab results would only reflect the effect of the hemorrhage, whereas assessing the fundus helps determine the cause and guides immediate treatment. The normal range for Hgb is 12 to 16 g/dL and Hct is 37 to 47 percent.
Choice D rationale
Assessing the uterine fundus is the priority because a large amount of lochia rubra (which is bright red, blood-like) indicates potential postpartum hemorrhage. The most common cause is uterine atony, a failure of the uterus to contract and compress the placental vessels. A firm, well-contracted fundus above the symphysis pubis prevents hemorrhage, so immediate palpation confirms the presence of uterus firmness and height and guides the next intervention, such as massage.
Correct Answer is C
Explanation
Choice A rationale
Administering oxygen is an appropriate intervention for fetal distress (normal FHR is 110-160 beats/min), but the immediate, precipitating cause of this sudden, profound bradycardia after amniotomy must first be determined. Oxygen is secondary to resolving the likely mechanical issue of a prolapsed cord.
Choice B rationale
Increasing intravenous fluids (IVFs) may improve maternal hydration and thus placental perfusion, which can sometimes help with mild FHR decelerations. However, it is not the immediate priority for a severe, acute drop to 80 beats/min after membrane rupture, which strongly suggests umbilical cord prolapse.
Choice C rationale
A sudden, severe FHR drop after amniotomy is highly indicative of umbilical cord prolapse, where the cord drops below the presenting part and is compressed. Inspecting the vagina (or performing a sterile vaginal examination) is the priority to visually or digitally confirm the presence of a prolapsed cord so immediate action can be taken to relieve compression.
Choice D rationale
Placing the client in the knee-chest position (or Trendelenburg) is done after confirming cord prolapse to use gravity to move the fetus off the compressed cord. The most immediate action is to diagnose the cause of the distress, as time is critical to prevent severe fetal hypoxia and injury.
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