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A nurse is assessing a newborn immediately following a scheduled cesarean delivery.
Which of the following assessments is the nurse's priority?

A.

Acrocyanosis.

B.

Respiratory distress.

C.

Hypothermia.

D.

Accidental lacerations.

E.

Superficial palpation.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Constructing a model airplane may require smaller parts and more intricate work, not ideal for a 4-year-old child.

Choice B rationale

Putting together a large-piece puzzle is suitable for fine motor skills development and can be done while in isolation.

Choice C rationale

Playing in the hallway would expose the child to other areas and people, defeating the purpose of airborne precautions.

Choice D rationale

Watching a video game in the playroom is not feasible as it would require leaving the isolation area.

Correct Answer is B

Explanation

Choice A rationale

Hanging crib toys are not suitable for a 12-month-old toddler as they are more appropriate for younger infants. Toddlers need toys that can stimulate their fine and gross motor skills, and hanging crib toys do not fulfill this need.

Choice B rationale

Large building blocks are ideal for a 12-month-old toddler as they help in developing fine motor skills, hand-eye coordination, and creativity. These blocks also encourage problem-solving and spatial awareness, which are crucial developmental milestones at this age.

Choice C rationale

Crayons and a coloring book are not the best choice for a toddler under contact precautions as they can be difficult to disinfect and might pose a risk of infection. Additionally, at 12 months, toddlers are still developing their pincer grasp and may not have the coordination for coloring.

Choice D rationale

Modeling clay is not suitable for a 12-month-old due to the potential choking hazard. Toddlers at this age tend to put objects in their mouths, and modeling clay can be difficult to keep clean under contact precautions.

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