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 C

Explanation

Choice A reason: Lethargy and hypotonia are concerning symptoms that indicate a significant decrease in muscle tone and alertness, which can be associated with various medical conditions. However, they may not require immediate intervention compared to a critically low heart rate.

Choice B reason: Elastic skin turgor is generally a normal finding, indicating good hydration status and skin elasticity. It does not require urgent attention.

Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a paediatric patient, indicating bradycardia. This requires immediate attention and intervention to ensure the patient's cardiovascular stability.

Choice D reason: A blood pressure of 100/54 mmHg is within a normal range for many paediatric patients and does not indicate an immediate emergency.

Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention.

A. Semi-Fowler's is the safest position for pushing. B. Choose a position you feel most comfortable. C. Sitting with your head elevated on two pillows makes pushing easier. D. It is normal if you're having a bowel movement.

Correct Answer is B

Explanation

Choice A reason: The statement that "Semi-Fowler's is the safest position for pushing" is not necessarily appropriate because the best position for pushing can vary from one woman to another. There is no single safest position universally recommended for all labouring women. The choice of position should be individualized based on the woman's comfort, progress of Labor, and any specific medical considerations. The Semi-Fowler's position involves lying semi-upright, which might be suitable for some but not for everyone.

Choice B reason: Advising the patient to "choose a position you feel most comfortable" is appropriate because it empowers the woman to listen to her body and adopt a position that feels natural and effective for her. Comfort plays a crucial role in the effectiveness of pushing and the overall Labor experience. This approach promotes a sense of control and autonomy for the labouring woman and aligns with best practices in patient-cantered maternity care.

Choice C reason: Suggesting that "sitting with your head elevated on two pillows makes pushing easier" may not be the best advice for every labouring woman. While this position might work for some, it is not universally effective or recommended. Labor positions should be flexible and adaptive to the individual's needs and comfort. Blanket recommendations can overlook the diversity of experiences and preferences among labouring women.

Choice D reason: Telling the patient that "it is normal if you're having a bowel movement" might address a concern some women have during Labor. However, it does not directly guide the woman on effective pushing positions. While it can be reassuring to mention that a bowel movement can occur during pushing, this statement alone is not sufficient as a primary piece of advice for managing the second stage of Labor.

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