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 C
Explanation
Choice A rationale
Dexamethasone does not directly stop labor contractions; instead, it is used to enhance fetal lung maturity.
Choice B rationale
Dexamethasone is not for infection prevention; antibiotics are used for that purpose in cases of premature rupture of membranes.
Choice C rationale
Dexamethasone is administered to enhance fetal lung maturity, reducing the risk of respiratory distress syndrome in preterm infants.
Choice D rationale
Dexamethasone is not used for pain relief in preterm labor; other medications are prescribed for pain management.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Pumping up the vacuum manually to the pressure indicated on the pump is a standard procedure but doesn't directly minimize liability.
Choice B rationale
Recognizing cup detachment (pop off) as a warning sign is critical, as it indicates excessive force or poor positioning, which can lead to fetal or maternal injury.
Choice C rationale
Limiting the cup's attachment to the fetal head to 5 to 10 minutes reduces the risk of scalp injury and other complications, thus minimizing liability.
Choice D rationale
Timing the procedure from insertion of the cup into the vagina until the birth is a guideline but doesn't specifically address liability concerns.
Choice E rationale
Releasing pressure between contractions prevents continuous suction on the fetal head, reducing the risk of injury and thereby minimizing liability.