The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about:
Select one:

Possible Meconium Aspiration Syndrome (MAS).

Possible polycythemia.

Possible Transient Tachypnea of the Newborn (TTN).

Possible Respiratory Distress Syndrome (RDS).

Answer and Explanation

The Correct Answer is D

Choice A Reason: Possible Meconium Aspiration Syndrome (MAS). This is an unlikely condition for this newborn, as MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inﬂammation, and infection. MAS usually aﬀects term or post-term infants who experience fetal distress or hypoxia in utero.

Choice B Reason: Possible polycythemia. This is an unrelated condition for this newborn, as polycythemia refers to an abnormally high number of red blood cells in the blood, which can increase blood viscosity and impair circulation.

Polycythemia may occur in infants who have delayed cord clamping, intrauterine growth restriction, maternal diabetes, or high altitude exposure.

Choice C Reason: Possible Transient Tachypnea of the Newborn (TTN). This is a less serious condition than RDS, as TTN is a mild respiratory problem that results from delayed clearance of fetal lung ﬂuid after birth. TTN causes rapid breathing, nasal ﬂaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth.

Choice D Reason: Possible Respiratory Distress Syndrome (RDS). This is a serious condition that requires immediate intervention and treatment, as RDS can lead to life-threatening complications such as pulmonary hemorrhage, pneumothorax, or bronchopulmonary dysplasia. RDS causes respiratory distress, nasal ﬂaring, retractions, grunting, and central cyanosis. It usually occurs within minutes to hours after birth.

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Correct Answer is D

Explanation

Choice A Reason: Taking the newborn to the nursery for the initial assessment. This is an ineﬀective intervention that disrupts parental atachment by separating the mother and the newborn. It also deprives the newborn of the benefits of skin to skin contact and breastfeeding.

Choice B Reason: Allowing the mother a chance to rest without the baby immediately after delivery. This is an unnecessary intervention that delays parental atachment by postponing the first contact between the mother and the newborn. It also ignores the mother's desire and readiness to hold and feed her baby.

Choice C Reason: Placing the newborn under a radiant warmer to do the initial assessment. This is an outdated intervention that hinders parental atachment by creating a physical barrier between the mother and the newborn. It also exposes the newborn to potential risks such as dehydration, hyperthermia, or eye damage.

Choice D Reason: Placing the newborn on the maternal abdomen and doing the initial assessment. This is because this intervention facilitates skin to skin contact, eye contact, and bonding between the mother and the newborn. It also enhances breastfeeding initiation, thermoregulation, and maternal-infant atachment.

A. Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. B. Palpating the woman's fundus for position and firmness. C. Encouraging the woman to push with her contractions. D. Alleviating perineal discomfort with the application of ice packs.

Correct Answer is A

Explanation

Choice A Reason: Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. This is an appropriate action for the nurse to perform during the third stage of labor, as it helps complete the process of labor and prevent complications.

Choice B Reason: Palpating the woman's fundus for position and firmness. This is an action that is done after the delivery of the placenta, not during. It is important to monitor the fundal height, location, and consistency to assess uterine involution and bleeding.

Choice C Reason: Encouraging the woman to push with her contractions. This is an action that is done during the second stage of labor, not the third. The second stage of labor is the period from full cervical dilation to the birth of the baby. The nurse's role is to support and coach the woman to push eﬀectively with her contractions.

Choice D Reason: Alleviating perineal discomfort with the application of ice packs. This is an action that is done after the delivery of the placenta, not during. It is a comfort measure that can reduce swelling, pain, and inﬂammation in the perineal area.

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The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After the birth of a newborn, the nursing intervention that most eﬀectively promotes parental atachment is: Select one:

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about:
Select one: