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","E"]
Explanation
Choice A rationale
Serving food in small, halved, or quartered pieces can help prevent choking, which is a significant concern for infants and young children who are still developing their chewing and swallowing skills.
Choice B rationale
Ensuring the mattress fits snugly against the sides of the crib prevents the infant from getting trapped between the mattress and the crib sides, reducing the risk of suffocation or injury.
Choice C rationale
Child-proof locks on cabinet doors prevent infants from accessing hazardous substances or dangerous objects that could cause harm. This is a crucial aspect of home safety for young children.
Choice D rationale
Setting the water heater at 65°C (149°F) is not recommended because it is too hot and can cause burns. The water heater should be set at a maximum of 48°C (118°F) to prevent scalding injuries.
Choice E rationale
Never leaving a child unattended during bath time is essential to prevent drowning, which can occur quickly and silently. Close supervision is necessary to ensure the child’s safety in the water. .
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.