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
Explanation
Choice A rationale
Monitoring for hypoglycemia is critical in newborns born to mothers with gestational diabetes, as they can experience significant drops in blood sugar levels post-birth due to the
sudden discontinuation of the high glucose supply from the mother.
Choice B rationale
Physiological jaundice is common in many newborns but does not represent the most immediate threat. It typically resolves within a few days with appropriate monitoring and care.
Choice C rationale
Hyperthermia can be a concern for newborns, but it is not the primary immediate complication in newborns born to gestational diabetic mothers. Hypoglycemia poses a greater
immediate risk.
Choice D rationale
Development of rash is generally a less critical concern and does not represent an immediate threat to the newborn’s well-being in comparison to hypoglycemia.
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.