A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is appropriate?
Place a pacifier in the baby's mouth.
Check the baby's diaper.
Have the mother feed the baby.
Assess the respiratory rate.
The Correct Answer is D
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.
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Correct Answer is A
Explanation
Choice A rationale
History of preterm birth is the principal risk factor for predicting preterm birth. Previous preterm births significantly increase the likelihood of subsequent preterm deliveries due to
underlying etiological factors.
Choice B rationale
Low prepregnancy weight is a risk factor but not as significant as a history of preterm birth. It can contribute to complications in pregnancy but does not have the same predictive value.
Choice C rationale
Smoking during pregnancy increases the risk of preterm birth but is not the principal risk factor. It is a modifiable behavior that contributes to poor pregnancy outcomes.
Choice D rationale
Obesity can impact pregnancy outcomes but is not the principal risk factor for preterm birth. It is associated with other complications rather than directly predicting preterm delivery.
Correct Answer is C
Explanation
Choice A rationale
While intravenous antibiotics are given during labor to prevent GBS transmission to the baby, it is not administered at home but in the hospital when labor begins.
Choice B rationale
GBS does not significantly increase the risk of intrauterine infection that requires daily temperature checks; it primarily poses a risk of neonatal infection during delivery.
Choice C rationale
GBS bacteria reside in the vagina and can be transmitted to the baby during delivery. Administering antibiotics during labor helps protect the baby from serious GBS-related illnesses.
Choice D rationale
GBS does not cause scarlet fever or the symptoms described; those are caused by different bacteria, namely Streptococcus pyogenes. .