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
Toddlers are at a stage where they are increasingly curious and mobile, which requires close supervision to ensure their safety. They are also prone to tantrums as they test
boundaries and express frustration due to limited communication skills. Effective management of tantrums and supervision can help parents guide their child's behavior and ensure
their safety.
Choice B rationale
Solitary play and identity development are more characteristic of older children. Toddlers engage more in parallel play, where they play alongside other children but not directly with
them. Encouraging solitary play is not as developmentally appropriate for toddlers.
Choice C rationale
Establishing trust is crucial in infancy when infants learn to trust their caregivers to meet their needs. Dental care should start around the toddler years, but the primary focus should
be on supervision and behavior management rather than dental care initiation.
Choice D rationale
Establishing relationships and developing self-confidence are vital across all developmental stages, but in toddlers, the priority lies in providing a safe environment and guiding
behavior through supervision and tantrum management.
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.