A nurse is caring for a newborn immediately following birth. The newborn has meconium-stained amniotic fluid.
Which of the following actions should the nurse take first?
Determine if the newborn's mouth and nose require bulb suctioning.
Initiate skin-to-skin contact between parent and newborn.
Place the newborn under a radiant warmer.
Provide tactile stimulation for the newborn.
The Correct Answer is A
Choice A rationale
Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.
Choice B rationale
While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.
Choice C rationale
Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.
Choice D rationale
Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.
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Correct Answer is A
Explanation
Choice A rationale
A respiratory rate of 12/min indicates that the respiratory depression caused by magnesium sulfate toxicity has been effectively reversed by calcium gluconate. Normal respiratory rate in adults is 12-20 breaths per minute.
Choice B rationale
Absent deep tendon reflexes indicate ongoing magnesium sulfate toxicity. Calcium gluconate administration should restore normal reflexes, not cause their absence.
Choice C rationale
Slurred speech is a sign of magnesium sulfate toxicity. Effective treatment with calcium gluconate should improve neurological function and resolve symptoms like slurred speech.
Choice D rationale
A urine output of 22 mL/hr is below the normal range and suggests renal impairment or ongoing toxicity. Effective treatment should result in an increase in urine output to within the normal range (greater than 30 mL/hr).
Correct Answer is A
Explanation
Choice A rationale
Irregular heartbeat (palpitations or arrhythmias) can indicate a serious cardiovascular side effect of nifedipine. It requires immediate medical attention as it could compromise
maternal and fetal circulation.
Choice B rationale
Hair loss is not a known adverse effect of nifedipine and generally does not pose a significant health risk. It is more commonly associated with hormonal changes rather than
medication side effects.
Choice C rationale
Increased salivation is not a common side effect of nifedipine. Nifedipine primarily affects the cardiovascular system rather than salivary glands.
Choice D rationale
Pause is not a recognized adverse effect related to nifedipine usage. The term itself is ambiguous and not typically associated with the pharmacological profile of nifedipine.