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 A
Explanation
Choice A rationale
This choice offers the toddler control and options within boundaries. By allowing the child to choose between two cups, it reduces the power struggle inherent in negativism, where the child often says "no" to assert independence.
Choice B rationale
This choice presents a direct option of now or later, which may still lead to refusal due to the toddler's negativism. Toddlers often respond better to choices that are less direct.
Choice C rationale
Asking if the child can take the medicine is likely to result in a "no" due to the nature of negativism at this developmental stage. It does not give the toddler a sense of control or choice.
Choice D rationale
Asking the child to be "good" places a moral judgment on taking the medicine, which is not developmentally appropriate and may lead to resistance.