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
Informing the client to expect dark-colored stools is inaccurate for methotrexate administration. Dark stools typically indicate gastrointestinal bleeding, not a side effect of methotrexate.
Choice B rationale
Wearing two pairs of gloves is necessary when handling methotrexate as it is a cytotoxic drug. This protects healthcare workers from accidental exposure to the medication, which can be harmful.
Choice C rationale
Methotrexate is typically administered intramuscularly or orally, not subcutaneously. Administering it subcutaneously is incorrect and would not be effective for treating an ectopic pregnancy.
Choice D rationale
While it is essential to counsel the client on safe intercourse practices, instructing to use a condom for only 7 days post-administration is not specific or relevant to the methotrexate therapy for ectopic pregnancy.
Correct Answer is D
Explanation
Choice A rationale
Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.
Choice B rationale
A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.
Choice C rationale
Late decelerations are concerning and not expected as they may indicate fetal distress.
Choice D rationale
Contractions lasting about 75 seconds are expected during the active phase of labor.