The physician has determined that a primigravid client in active labor requires a cesarean delivery because of cephalopelvic disproportion. After the delivery of a healthy neonate, the nurse should assess the neonate for which of the following first?
1. Nasopharyngeal secretions.
2. High-pitched cry.
3. Skull fracture.
4. Decreased muscle tone.
A neonate delivered by cesarean delivery has not had the benefit of the chest-squeezing action of a vaginal delivery, which helps remove some of the nasopharyngeal secretions. The nurse should place the neonate under the radiant warmer and suction the mouth and nares with a bulb syringe to remove nasopharyngeal secretions.
A high-pitched cry is associated with neurologic involvement or neonatal drug withdrawal and is unrelated to cesarean delivery. Skull fractures may occur with difficult vaginal deliveries and are not typically seen with cesarean deliveries. Decreased muscle tone is associated with oversedation, neurologic impairment, or use of general anesthesia.
CN: Health promotion and maintenance; CL: Analyze
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