A 38 weeks' gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery

Question

Which is the priority nursing diagnosis?

a. Risk for injury related to potential equipment malfunction of radiant warmer
b. Altered tissue perfusion related to use of medications during delivery process
c. Ineffective airway clearance due to mode of delivery and use of anesthetics
d. Risk for ineffective thermoregulation related to gestational age

Answer 1

ANS: C
Delivery via cesarean section may affect the newborn's ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk for airway concerns. There is no evidence to support that the equipment is malfunctioning. Although the use of medications may affect the newborn in terms of respiratory, cardiac, and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is at term based on reported gestational age and therefore is not a risk for ineffective thermoregulation because of this fact.