The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective thermoregulation related to heat loss to the environment.

Altered nutrition less than body requirement related to limited formula intake.

Altered urinary elimination related to post-circumcision status.

Ineffective airway clearance related to mucus and water secretions.

Answer and Explanation

The Correct Answer is D

Ineffective airway clearance related to mucus and water secretions. This is because newborns who are born via cesarean delivery are at risk for respiratory distress due to the lack of compression of the chest during birth. This can result in retained mucus and fluid in the lungs that can interfere with breathing and oxygenation. The nurse should prioritize clearing the airway and monitoring the respiratory status of the newborn.

Choice A is wrong because ineffective thermoregulation related to heat loss to the environment is not specific to cesarean delivery. All newborns are prone to heat loss due to their large surface area and thin skin. The nurse should maintain a warm and dry environment for the newborn and prevent exposure to cold surfaces.

Choice B is wrong because altered nutrition less than the body requirement related to limited formula intake is not specific to cesarean delivery. All newborns need adequate nutrition to support their growth and development. The nurse should monitor the intake and output of the newborn and assist with feeding as needed.

Choice C is wrong because altered urinary elimination related to post- circumcision status is not specific to cesarean delivery. Circumcision is an elective procedure that may or may not be performed on male newborns. The nurse should provide wound care and pain relief for the circumcised newborn and observe for signs of infection or bleeding.

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Correct Answer is C

Explanation

Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.

Choice A is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.

Choice B is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.

Choice D is incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.

A. Clear the respiratory tract. B. Dry the infant off and cover the head. C. Stimulate the infant to cry. D. Clamp the umbilical cord.

Correct Answer is A

Explanation

Clear the respiratory tract. This is because clearing the respiratory tract is the first step in the initial care of a newborn following vaginal delivery. The respiratory tract includes the nose, mouth, and lungs.

Clearing the respiratory tract helps the baby breathe more easily and prevents aspiration of amniotic fluid, blood, or mucus. The nurse can use a bulb syringe or a suction device to gently remove any fluid from the baby's nose and mouth.

Choice B is not correct because drying the infant off and covering the head is not the first action to take. Drying and covering the infant helps prevent heat loss and hypothermia, which are important for newborn care. However, this should be done after clearing the respiratory tract.

Choice C is not correct because stimulating the infant to cry is not the first action to take. Stimulating the infant to cry can help expand the lungs and improve oxygenation, which is also important for newborn care. However, this should be done after clearing the respiratory tract.

Choice D is not correct because clamping the umbilical cord is not the first action to take. Clamping and cutting the umbilical cord separates the baby from the placenta, which is no longer needed after birth. However, this should be done after clearing the respiratory tract.

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The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:

Correct Answer is C

Explanation

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Correct Answer is A

Explanation

When a newborn takes its first breath, what physical changes occur in the heart to increase oxygenation of the body?

Following delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. The appropriate intervention is:

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment.

To protect newborns from infection while in the nursery, the nurse plans to:

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature.

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should: