The nurse is preparing for the care of a baby about to be delivered by caesarean section. What interventions will the nurse include in the plan of care? Select all that apply.

Obtain an arterial blood gas.

Ensure thermoregulation.

Administer oxygen as needed.

Insert an orogastric tube.

Keep the head in a sniffing position.

Answer and Explanation

Correct Answer : B,C,E

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.

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Correct Answer is A

Explanation

Choice A reason: Applying a cold pack to the affected area is the most appropriate intervention for managing hemarthrosis (bleeding into the joint) in a patient with haemophilia A. Cold therapy helps reduce pain, swelling, and inflammation by constricting blood vessels, which can slow down bleeding. This intervention also provides comfort to the patient and helps manage the acute symptoms of hemarthrosis effectively.

Choice B reason: Administering ibuprofen for pain is not recommended for patients with haemophilia A because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding by inhibiting platelet function. Instead, acetaminophen (Tylenol) is often preferred for pain management in these patients as it does not have the same blood-thinning effects.

Choice C reason: Performing range-of-motion exercises is not appropriate during the acute phase of hemarthrosis. Movement and exercise can exacerbate bleeding and increase pain. It is essential to allow the joint to rest and stabilize before considering gentle range-of-motion exercises during the recovery phase. Immediate management should focus on controlling bleeding and reducing inflammation.

Choice D reason: Placing the leg in a dependent position (lower than the heart) is not recommended for managing hemarthrosis. Elevating the affected limb is a better approach as it helps reduce swelling and pain by promoting venous return and minimizing blood flow to the affected area. The dependent position can increase blood flow to the joint, potentially worsening the bleeding and swelling.

A. Encourage the patient to ambulate intermittently and change positions. B. Place the patient in the left lateral position and increase the oxytocin rate. C. Administer oxygen 10 litters per minute via a non-rebreather mask. D. Teach the patient to push when she feels the urge during contractions.

Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to ambulate intermittently and change positions can help alleviate early decelerations by improving uteroplacental blood flow and promoting fatal oxygenation. Movement and position changes can reduce compression on the umbilical cord and facilitate Labor progression.

Choice B reason: Placing the patient in the left lateral position can improve uteroplacental blood flow, but increasing the oxytocin rate is not indicated based on the current findings. Early decelerations are typically not a sign of Labor dystocia requiring oxytocin augmentation.

Choice C reason: Administering oxygen via a non-rebreather mask is generally reserved for situations where there is significant fatal distress or non-reassuring fatal heart rate patterns. Early decelerations are usually benign and do not necessitate supplemental oxygen.

Choice D reason: Teaching the patient to push when she feels the urge during contractions is appropriate during the second stage of Labor. However, the current findings with early decelerations do not indicate the need for this intervention at this time. The focus should be on monitoring and managing the fatal heart rate.

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