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 B
Explanation
Choice A rationale
Elevated BUN levels (25 mg/dL) can indicate kidney dysfunction, dehydration, or high protein intake. However, it’s not directly related to a prenatal complication, though it still
requires monitoring.
Choice B rationale
Hemoglobin (Hgb) of 10.2 mg/dL is below the normal range (11 to 16 mg/dL) and can indicate anemia. During pregnancy, anemia can lead to serious complications such as preterm
birth and low birth weight, making this result significant.
Choice C rationale
A fasting blood glucose level of 70 mg/dL falls within the normal range (70 to 110 mg/dL) and does not indicate a complication. Thus, it is not concerning in the context of prenatal
complications.
Choice D rationale
Hematocrit (Hct) of 32% is slightly below the normal range (33 to 47%), which can be common in pregnancy due to increased plasma volume. While monitoring is required, it’s not as
critical as anemia.
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).