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
A pincer grasp, using the thumb and index finger to pick up small objects, typically develops around 9 to 12 months of age, not at 4 months.
Choice B rationale
The posterior fontanel typically closes by the age of 2 to 3 months, so a 4-month-old infant would be expected to have a closed posterior fontanel. This finding is consistent with normal development.
Choice C rationale
Lateral incisors, the teeth on either side of the front teeth, typically erupt around 9 to 13 months of age, not at 4 months.
Choice D rationale
Sitting steadily without support generally occurs closer to 6 to 8 months of age, so it would not be expected in a 4-month-old infant.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Keeping the diaper loose in the front helps avoid pressure on the circumcision site, promoting healing and reducing discomfort for the infant.
Choice B rationale
A yellow crust or exudate forming on the circumcision site is a normal part of the healing process and should not be a cause for alarm. It is not an indication to call the doctor immediately unless other signs of infection or complications are present.
Choice C rationale
Notifying the healthcare provider in the case of significant bleeding is crucial. Excessive bleeding can indicate a complication that requires prompt medical attention to ensure the infant's safety and proper healing.
Choice D rationale
Applying petroleum jelly with each diaper change helps to protect the circumcision site from sticking to the diaper, promoting healing and reducing discomfort.