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 B
Explanation
Choice A rationale
The deltoid muscle is not recommended for newborns due to its small size and underdevelopment.
Choice B rationale
The vastus lateralis muscle is well-developed in newborns and has a large enough surface area to safely accommodate injections.
Choice C rationale
The gluteus maximus muscle is not suitable for newborn injections due to the risk of nerve damage.
Choice D rationale
The rectus femoris muscle is less commonly used due to the potential for more pain and discomfort.
Correct Answer is C
Explanation
Choice A rationale
Preoperational stage starts around age 2 to 7 years, characterized by symbolic thinking.
Choice B rationale
Concrete operational stage starts around age 7 to 11 years, involving logical thinking about concrete events.
Choice C rationale
Sensorimotor stage (birth to 2 years) is when infants know the world mostly in terms of their sensory impressions and motor activities.
Choice D rationale
Formal operational stage begins at approximately age 12 and involves abstract and hypothetical thinking.