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 D
Explanation
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.
Correct Answer is D
Explanation
Choice A rationale
Precipitous labor and birth are not directly associated with postpartum endometritis. The primary risk factors are related to infections during labor.
Choice B rationale
Postpartum endometritis is typically treated with a combination of antibiotics for 7-10 days, not a single dose of ampicillin or cephalosporin. A single dose would be insufficient for
treating the infection.
Choice C rationale
Postpartum endometritis is more common following cesarean birth due to increased risk of infection despite the use of sterile techniques during surgery.
Choice D rationale
Postpartum endometritis is associated with internal monitoring, amnioinfusion, prolonged labor, and prolonged rupture of membranes. These factors increase the risk of infection,
which can lead to endometritis.