The nurse is caring for a 14-year-old patient following myelography. What is the priority nursing action?

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: Pathologic jaundice is an abnormal condition that typically appears within the first 24 hours of life. It often indicates an underlying health problem and requires prompt medical evaluation and intervention.

Choice B reason: Both pathologic and physiologic jaundice are not treated with exchange transfusions of maternal O-negative blood. Exchange transfusions are only considered in severe cases of jaundice, typically for pathologic jaundice when other treatments are ineffective.

Choice C reason: Physiologic jaundice is a common and usually harmless condition that occurs in many newborns, peaking around the second or third day of life. It does not result in kernicterus, a rare but severe form of brain damage caused by very high levels of bilirubin. Pathologic jaundice, if untreated, may lead to kernicterus.

Choice D reason: Physiologic jaundice generally does not require transfer to the neonatal intensive care unit. It is usually managed with simple interventions, such as phototherapy, and often resolves on its own as the newborn's liver matures and becomes more efficient at processing bilirubin.