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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Developing a plan of care with the child and family is important, but it does not explicitly address the need for cultural competence. This approach is cantered around collaboration rather than cultural sensitivity.
Choice B reason: Providing future-based care for culturally diverse children is vague and does not directly indicate an understanding or application of cultural competence in the current care situation.
Choice C reason: Treating all children the same regardless of their culture is contrary to the principles of culturally competent care. Culturally competent care involves recognizing and respecting the cultural differences that impact the child's health and tailoring the care to meet those unique needs.
Choice D reason: Assessing the child's culture and providing care based on the findings demonstrates an understanding and application of culturally competent care. This approach ensures that the care is respectful of and responsive to the cultural needs of the child and family.
Correct Answer is D
Explanation
Choice A reason: Haemophilia patients often require Factor VIII replacement therapy before procedures such as dental cleanings to prevent bleeding. The statement that the child does not need Factor VIII before a dental cleaning indicates a misunderstanding of the need for prophylactic treatment.
Choice B reason: Aspirin is contraindicated for children with haemophilia as it can inhibit platelet function and increase the risk of bleeding. The statement that it is okay to use aspirin reflects a lack of understanding of the appropriate pain management for haemophilia.
Choice C reason: While it is important for children with haemophilia to stay active, certain high-impact or contact sports may increase the risk of bleeding and should be avoided. The statement that there are no limitations on the type of activities indicates a lack of awareness about the need to choose safe activities.
Choice D reason: Swimming is a low-impact activity that is generally safe and beneficial for children with haemophilia. It promotes cardiovascular fitness and muscle strength without putting undue stress on the joints or increasing the risk of bleeding. This statement demonstrates an understanding of appropriate activity choices for a child with haemophilia.
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