Maternity Nursing Q 114
To ensure that the baby will breathe as soon as the head is delivered, the nurse’s priority action is to
A. Slap the baby’s buttocks to make the baby cry.
B. Suction the nose and mouth to remove mucous secretions.
C. Clamp the cord about 6 inches from the base.
D. Check the baby’s color to make sure it is not cyanotic.
Correct Answer: B. Suction the nose and mouth to remove mucous secretions.
Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that may be present allowing for better breathing. Also, if mucus is in the nose and mouth, aspiration of the mucus is possible which can lead to aspiration pneumonia. (Remember that only the baby’s head has come out as given in the situation.)
Option A: Earlier, many doctors would hold the baby upside down firmly around his legs and then slap the butt gently. This not only causes slight pain to the child, but the motion also helps loosen any residues that might be obstructing the airways. Constantly doing so can irritate the child enough to begin crying.
Option C: Late cord clamping (performed approximately 1–3 min after birth) is recommended for all births while initiating simultaneous essential neonatal care. Early umbilical cord clamping (less than 1 min after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation.
Option D: When a baby is first born, the skin is a dark red to purple color. As the baby starts to breathe air, the color changes to red. This redness normally starts to fade on the first day. A baby’s hands and feet may stay bluish in color for several days. This is a normal response to a baby’s underdeveloped blood circulation. But blue coloring of other parts of the body isn’t normal.