A nurse is assessing a newborn immediately following a scheduled cesarean delivery.
Which of the following assessments is the nurse's priority?
Acrocyanosis.
Respiratory distress.
Hypothermia.
Accidental lacerations.
Superficial palpation.
The Correct Answer is B
Choice A rationale
Acrocyanosis is a common and typically benign condition in newborns, characterized by bluish discoloration of the hands and feet. It is not an immediate priority.
Choice B rationale
Respiratory distress is the priority assessment for a newborn immediately following a cesarean delivery. Ensuring the newborn has a patent airway and is breathing effectively is crucial for their survival and immediate well-being.
Choice C rationale
Hypothermia is a concern for newborns, but respiratory distress takes precedence as an immediate life-threatening condition.
Choice D rationale
Accidental lacerations can occur during a cesarean delivery, but they are usually not life-threatening and can be addressed after ensuring the newborn's respiratory status is stable. .
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Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Measles, mumps, rubella (MMR) vaccine is recommended for a 1-year-old child as it protects against these three highly contagious viral diseases. This vaccine is typically given in two doses, with the first dose administered at 12-15 months.
Choice B rationale
Tetanus, diphtheria, and pertussis (TDaP) vaccine is not typically given at 1 year of age. The primary series is given in infancy, and the TDaP booster is given at 4-6 years of age.
Choice C rationale
Inactivated polio virus (IPV) vaccine is part of the routine vaccination schedule for children. It protects against polio, a serious disease that can cause paralysis. The IPV vaccine is given in multiple doses, starting at 2 months of age.
Choice D rationale
Varicella (VAR) vaccine protects against chickenpox, a highly contagious disease. It is recommended for children at 12-15 months of age and is usually given in two doses.
Choice E rationale
Human papillomavirus (HPV) vaccine is not recommended for a 1-year-old child. It is typically given to preteens and teens to protect against HPV infections that can lead to cervical cancer and other diseases.
Correct Answer is A
Explanation
Choice A rationale
It is common for children who are hospitalized to regress temporarily in their behavior, including toilet training. Stress, unfamiliar environments, and illness can contribute to this regression. Assuring the parents that the child’s skills will return when they feel better helps alleviate their concerns.
Choice B rationale
Asking why it bothers the parent that their child has wet the bed may come across as insensitive or confrontational. It does not provide support or reassurance to the parent.
Choice C rationale
Telling the parent not to worry about the child wetting the bed because the child did not seem upset dismisses the parent’s feelings and does not address the underlying issue of the child’s regression.
Choice D rationale
Sharing personal experiences and saying it doesn’t bother the nurse may seem empathetic but does not provide the professional reassurance and support the parents need. It shifts the focus to the nurse rather than addressing the parents' concerns.