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","B","C","D"]
Explanation
Choice A rationale
Inspection is always the first step in an abdominal assessment. It involves visually examining the abdomen for any abnormalities such as distention, masses, or scars.
Choice B rationale
Auscultation follows inspection and involves listening to bowel sounds with a stethoscope. This helps to assess the presence and frequency of peristalsis.
Choice C rationale
Deep palpation is performed after superficial palpation to identify any deep-seated abnormalities or pain. It helps in assessing the size, shape, consistency, and mobility of abdominal organs.
Choice D rationale
Superficial palpation is performed before deep palpation to detect any tenderness, muscle resistance, or superficial masses. It is done gently to avoid causing discomfort to the child.
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.