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 B
Explanation
Choice A rationale
Checking for ketones in urine is related to metabolic conditions like diabetic ketoacidosis, not directly relevant to the immediate care of an eclamptic client.
Choice B rationale
Padding the bed rails and headboard helps prevent injury during seizures, which is crucial in managing a client with eclampsia.
Choice C rationale
Providing visual and auditory stimulation can increase the risk of further seizures in an eclamptic client. Reducing stimulation is usually recommended.
Choice D rationale
Placing the bed in the high Fowler's position is not appropriate for managing a client post-seizure. The priority is ensuring airway patency and preventing injury.
Correct Answer is B
Explanation
Choice A rationale
Administering oxytocin during shoulder dystocia can exacerbate the problem by increasing uterine contractions, making it harder to deliver the baby's shoulder.
Choice B rationale
Flexing the client's thighs sharply toward her abdomen, known as the McRoberts maneuver, helps to widen the pelvis and can often resolve shoulder dystocia by changing the angle of the pelvic bones.
Choice C rationale
While applying oxygen is a standard practice to improve maternal and fetal oxygenation, it does not specifically address shoulder dystocia and is not a primary intervention.
Choice D rationale
Applying downward pressure on the fundus is contraindicated as it can worsen shoulder dystocia by further impacting the shoulder against the pelvic bone.