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 D
Explanation
Choice A rationale
Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.
Choice B rationale
Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.
Choice C rationale
Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.
Choice D rationale
Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.
Correct Answer is C
Explanation
Choice A rationale
The Industry vs. Inferiority stage, according to Erikson, occurs from age 6 to puberty, where children focus on learning, developing skills, and striving for competence. A 20-month-old
child is not yet in this stage.
Choice B rationale
The Trust vs. Mistrust stage is the earliest stage in Erikson's theory, occurring from birth to about 18 months. While a 20-month-old child has recently transitioned out of this stage, it
is not the stage applicable to their current developmental phase.
Choice C rationale
The Autonomy vs. Shame and Doubt stage occurs from approximately 18 months to 3 years. At 20 months, children are striving for independence, making choices, and developing a
sense of self-control, which is characteristic of this stage.
Choice D rationale
The Initiative vs. Guilt stage occurs from ages 3 to 6 years, where children begin to assert power and control through directing play and other social interactions. A 20-month-old child
is not in this stage yet.