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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The baby sleeps with the mother in bed. This is because sleeping with the baby in the same bed increases the risk of sudden infant death syndrome (SIDS), suffocation, strangulation, and entrapment. The nurse should have assessed the mother’s sleeping arrangements for the baby and provided education on safe sleep practices before discharge. The nurse should advise the mother to place the baby on a firm surface, such as a crib or bassinet, in the same room but not in the same bed as the mother.
Choice B is wrong because having windows covered with screens is not a sign of inadequate home assessment. Screens can help prevent insects and other animals from entering the home and posing a health hazard.
Choice C is wrong because having a refrigerator in the kitchen is not a sign of inadequate home assessment. A refrigerator can help store food and breast milk safely and prevent spoilage and contamination.
Choice D is wrong because having a changing area for the baby is not a sign of inadequate home assessment. A changing area can help keep the baby clean and comfortable and prevent diaper rash and infection.
Correct Answer is D
Explanation
Determine the client’s temperature. This is because shaking chills during the immediate postpartum period can be a sign of infection, such as endometritis or mastitis. Infection is a serious complication that can lead to sepsis and shock if not treated promptly. The nurse should measure the client’s temperature and look for other signs of infection, such as foul-smelling lochia, breast tenderness, or tachycardia.
Choice A is wrong because placing the client on seizure precautions is not indicated for shaking chills. Seizure precautions are used for clients who have eclampsia or other conditions that increase the risk of seizures.
Choice B is wrong because covering the client with warm blankets may not be helpful for shaking chills. Warm blankets may increase the body temperature and worsen the infection.
Choice C is wrong because notifying the charge nurse is not the first action the nurse should take. The nurse should assess the client’s condition before reporting to the charge nurse or the provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today