You come in to your patient and hear a cooing sound coming from the baby. The family says ‘’Oh listen to the cute noise the baby is making" You assess some more and realize that the coos are consistent with the babies respirations. You:
Don't concern yourself with it and agree with the family that it is cute
Begin Resuscitation on the infant
Realize that the baby is grunting and continue to assess infant's respiratory status
Put the baby on Nasal Cannula at 100%
The Correct Answer is C
A) Don’t concern yourself with it and agree with the family that it is cute:
While it may seem cute, it is important to recognize that abnormal sounds like grunting in a newborn can be a sign of respiratory distress. Grunting is a compensatory mechanism used by the infant to help keep the alveoli open during exhalation, indicating that the baby may be struggling to maintain adequate oxygenation. Ignoring these signs could delay necessary interventions.
B) Begin Resuscitation on the infant:
Resuscitation would be indicated if the baby were showing signs of severe respiratory distress, such as a significant drop in heart rate, poor oxygenation, or altered mental status. However, a cooing sound that is consistent with the baby’s respiratory effort does not immediately warrant resuscitation. The correct approach is to assess the baby further to determine if the issue is respiratory distress or something less severe.
C) Realize that the baby is grunting and continue to assess infant's respiratory status:
Grunting in a newborn can be a sign of respiratory distress. It is important to differentiate between normal sounds (like cooing) and abnormal sounds (like grunting) that might indicate the infant is working harder to breathe. In this scenario, the nurse should continue to assess the baby’s respiratory rate, effort, oxygen saturation, and overall condition. If the grunting persists or worsens, further intervention may be required.
D) Put the baby on Nasal Cannula at 100%:
While supplemental oxygen may be necessary if the infant is in respiratory distress, placing the baby on nasal cannula at 100% oxygen without further assessment is premature. First, the nurse should assess the baby's overall respiratory status, including oxygen saturation, effort, and any signs of distress before deciding if oxygen therapy is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Excessive uterine bleeding:
Bladder distention can displace the uterus to the right and elevate it above the umbilicus, interfering with uterine contraction. This displacement prevents the uterus from contracting effectively, which can lead to excessive uterine bleeding, a serious complication. When the uterus does not contract properly, it may not effectively compress the blood vessels, increasing the risk of hemorrhage. Immediate attention to bladder distention is crucial to prevent this potentially life-threatening issue.
B. Urinary tract infection:
While urinary tract infections (UTIs) can occur in the postpartum period, especially if the bladder is not emptied completely, they are not the most immediate or serious consequence of bladder distention. The priority is to address the distended bladder to prevent complications like excessive bleeding. A UTI would be a concern later, but it would not be the most acute risk following delivery.
C. Ruptured bladder:
A ruptured bladder is a rare and severe complication but is not the most likely consequence of bladder distention in the immediate postpartum period. Bladder rupture typically occurs due to significant trauma or extreme distention, which is not common in this situation. The more immediate concern is uterine atony and hemorrhage due to displaced uterine tone from bladder distention.
D. Bladder wall atony:
Bladder wall atony could result from severe bladder distention, causing difficulty in voiding. However, this is not the most serious consequence immediately after birth. Bladder distention typically results in impaired uterine contraction, which causes bleeding rather than atony of the bladder wall itself. Addressing bladder distention will help prevent complications such as hemorrhage rather than focusing on bladder atony initially.
Correct Answer is A
Explanation
A) Put baby to breast for non-nutritive sucking to calm baby:
Non-nutritive sucking (sucking without feeding) is a natural way for babies to self-soothe. It can help calm a fussy infant and also promote bonding between mother and baby. This action also stimulates milk production in the mother. It's a safe and effective way to comfort the baby without introducing unnecessary interventions. Non-nutritive sucking can help regulate the baby's sucking reflexes and provide comfort until the next feeding.
B) Give the baby pacifier:
While pacifiers can help some babies self-soothe, they can interfere with breastfeeding, especially in the early days. Introducing a pacifier too soon may confuse the baby’s natural sucking pattern and affect the latch, which can impact breastfeeding success. It’s typically recommended to wait until breastfeeding is well-established, around 3-4 weeks, before introducing a pacifier.
C) Put the baby in the nursery so mom can get some rest:
While maternal rest is important, removing the baby from the mother's care in the early postpartum period may interfere with the breastfeeding process. Breastfeeding on demand is crucial for establishing a good milk supply, and keeping the baby close for frequent feedings (and comfort) will help with this. Encouraging rest is important, but it shouldn't come at the expense of bonding and feeding.
D) Supplement with formula:
There is no indication that the baby is not getting enough nutrition at this point. Fussy behavior between feedings is common in newborns and can be due to various factors such as the baby's need for comfort, a growth spurt, or a short interval between feedings. Supplementing with formula is not necessary unless there is a clear indication of inadequate milk supply or other medical concerns, which isn’t evident in this situation.
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