Nokea
A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?
- A. Weak, ineffective suck, and scalp edema
- B. Molding of the head and jitteriness
- C. Shrill, high pitched cry, and tachypnea
- D. Hypothermia and hemoglobin of 12.5 g/dL
Correct Answer: A
Rationale: The correct answer is A: Weak, ineffective suck, and scalp edema. Forceps delivery can cause head trauma leading to facial nerve injury, resulting in weak suck and scalp edema. Molding of the head (choice B) is a normal finding after vaginal birth. Jitteriness (choice B) may be due to immaturity rather than a complication of forceps delivery. A shrill, high-pitched cry and tachypnea (choice C) are more indicative of respiratory distress, not specific to forceps delivery. Hypothermia and hemoglobin of 12.5 g/dL (choice D) are not directly related to complications of forceps delivery.
You may also like to solve these questions
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletal traction. Which of the following nursing interventions is the most appropriate?
- A. Position the weights securely against the foot of the bed.
- B. Provide small frequent high-fat meals to the child.
- C. Compare pulses on affected site to contralateral side.
- D. Provide diversional activities to minimize the child's movement.
Correct Answer: C
Rationale: The correct answer is C: Compare pulses on affected site to contralateral side. This is the most appropriate nursing intervention because it assesses for any circulatory compromise due to the skeletal traction. Checking pulses helps monitor perfusion distal to the fracture site and ensures early detection of any complications like compartment syndrome. Positioning the weights against the foot of the bed (A) is incorrect as it can cause uneven traction. Providing high-fat meals (B) and diversional activities (D) are irrelevant to the immediate care of the child's fracture.
A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs?
- A. White vaginal discharge
- B. Dull backache
- C. Frequent,urgent urination
- D. Abdominal pain
Correct Answer: D
Rationale: The correct answer is D: Abdominal pain. Abdominal pain is a significant danger sign in pregnancy that could indicate various complications such as ectopic pregnancy, placental abruption, or preterm labor. Prompt medical evaluation is crucial to ensure the health of both the mother and the baby. White vaginal discharge (A) is not necessarily a danger sign unless it is accompanied by other symptoms like itching or a foul smell. Dull backache (B) is common in pregnancy and usually not a cause for concern unless severe or accompanied by other symptoms. Frequent, urgent urination (C) is a common symptom in pregnancy due to increased pressure on the bladder and is not typically a danger sign unless associated with pain or burning.
A 1-year-old receives routine health maintenance care at the pediatric clinic. The child receives an MMR immunization. The mother asks the nurse, 'When will my child get the next dose of MMR vaccine?' Which is the correct response by the nurse?
- A. In six months with the next DPT
- B. No further vaccination needed
- C. With the Hepatitis B series
- D. After the child is 10 years of age
Correct Answer: D
Rationale: A second MMR, often called a booster, will be needed when the child enters middle school at age eleven or twelve years of age. This ensures full immunity from the diseases covered by the MMR vaccine.
A nurse is performing a routine physical examination on an adolescent client who asks, 'Why do I have to use a condom if my girlfriend is on the pill?' Which of the following is the most appropriate response by the nurse?
- A. You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy.
- B. Using a condom allows you to share the responsibility for birth control.
- C. Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed.
- D. Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases.
Correct Answer: D
Rationale: The correct answer is D. The nurse should explain that while oral contraceptives are highly effective in preventing pregnancy, they do not protect against sexually transmitted diseases (STDs). This is important because even if the girlfriend is on the pill, using a condom is necessary to prevent STD transmission. Adolescents are at higher risk for STDs, so it is crucial to emphasize the importance of dual protection. Choice A is incorrect as it does not specifically address the risk of STD transmission. Choice B is incorrect because it focuses on shared responsibility rather than the health implications of using a condom. Choice C is incorrect as it emphasizes the effectiveness of oral contraceptives rather than the need for STD protection.