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
Explanation
Choice A rationale
Proximodistal development refers to growth from the center of the body outward to the extremities. An infant grabbing with their whole hand (palmar grasp) before developing a
pincer grasp demonstrates this pattern, as they gain control of arm movements before fine motor skills in the fingers.
Choice B rationale
Cephalocaudal development refers to growth from head to toe, such as gaining control over head and neck muscles before the limbs. This does not directly explain the grasping
behavior described.
Choice C rationale
Distoproximal is not a recognized term in developmental science and does not describe a growth pattern.
Choice D rationale
Top-to-bottom is another way of describing cephalocaudal development but does not specifically address the described behavior in grasping development. .
Correct Answer is A
Explanation
Choice A rationale
This choice offers the toddler control and options within boundaries. By allowing the child to choose between two cups, it reduces the power struggle inherent in negativism, where the child often says "no" to assert independence.
Choice B rationale
This choice presents a direct option of now or later, which may still lead to refusal due to the toddler's negativism. Toddlers often respond better to choices that are less direct.
Choice C rationale
Asking if the child can take the medicine is likely to result in a "no" due to the nature of negativism at this developmental stage. It does not give the toddler a sense of control or choice.
Choice D rationale
Asking the child to be "good" places a moral judgment on taking the medicine, which is not developmentally appropriate and may lead to resistance.