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%

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Apply an ice pack to the perineum:
For a second-degree perineal laceration sustained during delivery, ice application is an important intervention within the first 24 hours to reduce swelling, pain, and inflammation in the perineal area. Ice packs help constrict blood vessels, decrease tissue edema, and provide analgesic effects. This intervention is most effective immediately after delivery and within the first 2-4 hours to help manage pain and swelling at the site of the laceration.

B) Teach the woman to insert nothing into her rectum:
While it is true that women with perineal lacerations should avoid rectal trauma or anything inserted into the rectum (e.g., rectal thermometers, suppositories) for a period of time, this is not the most urgent or immediate action for this patient. The primary concern at this point is managing the acute symptoms related to the laceration (e.g., swelling, pain), which is best managed with ice packs and other measures. Teaching about avoiding rectal insertion would be important later in the postpartum period.
C) Advise the woman to sit on a pillow:
While sitting on a pillow can reduce pressure on the perineum and help with comfort, it is not the most immediate intervention for this woman, especially in the first few hours postpartum. The priority should be addressing swelling and pain associated with the perineal laceration, which is best managed with ice, as it helps with the acute management of the injury.

D) Advise the woman to use sitz bath after each void:
A sitz bath can be helpful for perineal healing in the postpartum period, but it is typically recommended after the first 24 hours post-delivery, after the initial swelling has gone down. During the first few hours to days postpartum, ice packs are generally the preferred intervention to manage swelling and pain, while sitz baths are often advised later to promote comfort, healing, and circulation in the perineum.

A. Bulb syringe in crib B. Secure hugs tag on and alarms activated C. ID bands match with mom's ID bands D. infant on their back to sleep E. All of the above

Correct Answer is E

Explanation

A) Bulb syringe in crib:
While a bulb syringe can be useful for clearing the infant’s airway in case of respiratory distress, keeping it in the crib is not an optimal safety practice. The syringe should be readily available but not within reach of the infant, as it could be a choking hazard if mishandled. Ideally, it should be stored in an easily accessible area but not within the crib.

B) Secure hugs tag on and alarms activated:
Ensuring that the infant has a security tag (often referred to as a "Hugs" tag) that is properly placed and that alarms are activated is an important safety measure to prevent infant abductions. Hospitals typically use electronic security systems that alert staff if the infant is removed from the designated area without proper authorization. This intervention is essential for maintaining safety in the hospital setting.

C) ID bands match with mom's ID bands:
It is critical that the infant's ID band matches the mother's ID band. This helps prevent any mix-up or baby swap and ensures that the infant is properly identified at all times. Regular checks should be made to verify that the bands match and remain secure throughout the hospital stay.

D) Infant on their back to sleep:
Placing the infant on their back to sleep is a key guideline for reducing the risk of Sudden Infant Death Syndrome (SIDS). This position has been proven to be the safest for infants and is a crucial practice for their well-being. Educating parents and caregivers about safe sleep practices is vital for infant safety.

E) All of the above:
All of these practices are part of a comprehensive safety plan for the infant. Ensuring that the infant is safely secured with proper identification, preventing any risk of abduction, promoting safe sleep practices, and ensuring that airway equipment is available are all essential measures in maintaining the safety of the newborn. Therefore, the correct response is "All of the above."

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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:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a postpartum patient who experienced a second-degree laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?

Correct Answer is A

Explanation

You know that infant safety is important so which of the following should be in place to maintain infant safety:

Correct Answer is E

Explanation

A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of sitz bath TID, and a stool softener. What information is most closely correlated with these orders?

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