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A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is appropriate?

A.

Place a pacifier in the baby's mouth.

B.

Check the baby's diaper.

C.

Have the mother feed the baby.

D.

Assess the respiratory rate.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Methylergonovine (Methergine) is used to manage postpartum hemorrhage by stimulating uterine contractions. It is especially useful in cases like this where rapid uterine tone is needed.

Choice B rationale

Magnesium sulfate is used to prevent seizures in preeclamptic patients, not to manage postpartum hemorrhage. This choice is incorrect in this context.

Choice C rationale

Carboprost-tromethamine (Hemabate) is also used for treating postpartum hemorrhage but is typically a secondary option to methylergonovine and may have more side effects.

Choice D rationale

Fresh frozen plasma (FFP) is used to replace clotting factors in cases of coagulopathy, not as a primary intervention for postpartum hemorrhage in this patient.

Correct Answer is D

Explanation

Choice A rationale

Placental abruption is characterized by abdominal pain, vaginal bleeding, and uterine tenderness. It does not cause dyspnea, hypotension, frothy sputum, or loss of consciousness.

Choice B rationale

Uterine rupture typically presents with severe abdominal pain, abnormal fetal heart rate patterns, and vaginal bleeding. Shock can occur, but not frothy sputum or sudden dyspnea.

Choice C rationale

Uterine inversion leads to pain, hemorrhage, and shock. It does not present with frothy sputum or sudden dyspnea.

Choice D rationale

Anaphylactoid syndrome (amniotic fluid embolism) results from amniotic fluid entering maternal circulation, causing an anaphylactic reaction. Symptoms include sudden dyspnea, hypotension, frothy sputum, and loss of consciousness, matching the described scenario. .

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