Safe, Effective Care Environment
59. A client, who is a 28-year-old gravida 4, para 3, presents to labor and delivery with the fetal head crowning. A physician is called for an emergent delivery, but has not yet arrived. After the neonate's head is delivered, which nursing intervention would be the most appropriate?
. Check for a nuchal cord.
. Place antibiotic ointment in the infant's eyes.
. Use a DeLee suction to remove secretions.
. Assess the neonate for heart rate and respirations.
Test-Taking Tip
Think "cord" as the first action after delivery of the head and before the shoulders and body. Picture the cardinal movements and the process of delivery.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Accident Prevention and Injury Prevention
Safe, Effective Care Environment
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Answer 1 is correct because, before delivery of the neonate's body, it is important to check for a cord around the neonate's neck. It is the first action after delivery of the head and before the shoulders are delivered. Answer 2 is incorrect because antibiotic ointment in the infant's eyes can wait for up to an hour. It is not a priority after the delivery of the head. Answer 3 is incorrect because the DeLee suction is no longer used to remove secretions; a bulb syringe should be used to remove secretions prior to delivery of the neonate's body. Answer 4 is incorrect because the body needs to be delivered before the heart rate and respirations can be evaluated. This is not the first action after delivery of the neonate's head.