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
It is common for children who are hospitalized to regress temporarily in their behavior, including toilet training. Stress, unfamiliar environments, and illness can contribute to this regression. Assuring the parents that the child’s skills will return when they feel better helps alleviate their concerns.
Choice B rationale
Asking why it bothers the parent that their child has wet the bed may come across as insensitive or confrontational. It does not provide support or reassurance to the parent.
Choice C rationale
Telling the parent not to worry about the child wetting the bed because the child did not seem upset dismisses the parent’s feelings and does not address the underlying issue of the child’s regression.
Choice D rationale
Sharing personal experiences and saying it doesn’t bother the nurse may seem empathetic but does not provide the professional reassurance and support the parents need. It shifts the focus to the nurse rather than addressing the parents' concerns.
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.