Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.
The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.
Which action should the nurse implement next?
Give blow-by oxygen via cannula.
Start IV infusion in a scalp vein.
Assist neonatologist with intubation.
Provide positive pressure ventilation.
Provide positive pressure ventilation.
The Correct Answer is D
Choice A rationale
Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.
Choice B rationale
Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.
Choice C rationale
Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.
Choice D rationale
Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Covering the lesion with a dressing is not an appropriate action as it will not prevent the transmission of herpes to the newborn. Herpes simplex virus can be transmitted to the neonate during delivery, and covering the lesion does not eliminate the risk.
Choice B rationale
Blood cultures are not indicated for managing active herpes lesions in a client with spontaneous rupture of membranes. This action does not address the immediate risk of transmission of the virus to the newborn.
Choice C rationale
Preparing for a cesarean section is the appropriate action because it reduces the risk of neonatal herpes transmission. Neonatal herpes can lead to severe complications, and a cesarean section is recommended to minimize the risk of exposure to the virus during vaginal delivery.
Choice D rationale
Administering penicillin is not appropriate for treating herpes lesions. Penicillin is an antibiotic effective against bacterial infections, but herpes is caused by a virus. Antiviral medications are required to manage herpes infections.
Correct Answer is C
Explanation
Choice A rationale
A weight gain of 2 pounds (0.91 kg) in a 34-week gestation multigravida is generally considered normal. During the third trimester, it is typical for a pregnant woman to gain around 0.5 to 1 pound per week. This weight gain helps support the growing fetus and prepare the mother's body for labor and breastfeeding. However, sudden or excessive weight gain could indicate fluid retention or preeclampsia, but a 2-pound gain alone is not necessarily a concern.
Choice B rationale
1+ edema on the lower extremities is a common finding during pregnancy, especially in the later stages. It is usually due to increased blood volume and pressure on the pelvic veins from the growing uterus, which can slow the return of blood from the legs. While some degree of edema is normal, particularly in the ankles and feet, it is important to monitor for sudden or severe swelling, which could be a sign of preeclampsia.
Choice C rationale
A fundal height of 30 cm at 34 weeks gestation is concerning because it is less than the expected measurement. Fundal height typically corresponds to gestational age in centimeters (±2 cm). Therefore, at 34 weeks, the expected fundal height would be between 32 and 36 cm. A smaller fundal height could indicate intrauterine growth restriction (IUGR), oligohydramnios, or other fetal development issues, which require further evaluation by the healthcare provider.
Choice D rationale
A fetal heart rate (FHR) of 110 beats per minute (bpm) is within the normal range for a fetus. The normal FHR typically ranges from 110 to 160 bpm. Although 110 bpm is on the lower end of the normal range, it is still considered acceptable. Significant deviations from the normal range, either too low (bradycardia) or too high (tachycardia), could indicate fetal distress and require immediate attention.
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