Nokea
A nurse is assessing a newborn following a forceps assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method?
- A. Hypoglycemia
- B. Polycythemia
- C. Facial Palsy
- D. Bronchopulmonary dysplasia
Correct Answer: C
Rationale: Facial Palsy is a complication that may occur following a forceps-assisted birth. Forceps delivery carries the risk of exerting pressure on the infant's facial nerves, leading to temporary facial weakness or paralysis. This condition is known as facial palsy. It typically resolves on its own without long-term consequences, but careful monitoring and follow-up are necessary.
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A newborn's birth was prolonged because the shoulders were very wide. The nurse performing the assessment would be particularly observant for a problem with the:
- A. Moro reflex
- B. Plantar reflex
- C. Babinski reflex
- D. Stepping reflex
Correct Answer: A
Rationale: The Moro reflex is a normal infantile reflex that is typically present at birth and disappears around 4-6 months of age. This reflex is triggered by a sudden loss of support or a loud noise, causing the infant to throw back the head and extend the arms in a gesture as if trying to grab something. In a situation where the newborn's birth was prolonged due to wide shoulders, there is a higher risk of injury to the brachial plexus (nerves that control arm movement) during delivery. Damage to the brachial plexus can result in weakness or paralysis of the affected arm, and this may impact the Moro reflex as it involves the arms' movement. Therefore, the nurse would be particularly observant for any abnormality or lack of response in the Moro reflex as it may indicate potential nerve injury related to the difficult birth.
Which congenital defects in a newborn are associated with long-term parenting problems? (Select all that apply.)
- A. Polydactyl
- B. Cleft lip and palate
- C. Ventral septal defect
- D. Ambiguous genitalia
Correct Answer: B
Rationale: 1. Cleft lip and palate: Parents of a newborn with a cleft lip and palate may face challenges related to feeding difficulties, speech development issues, and concerns about their child's appearance. These issues can require additional medical interventions and support, leading to long-term parenting stress and psychological strain.
The nurse is preparing a client for a nonstress test. What instruction should the nurse provide?
- A. Avoid eating or drinking before the test.
- B. Press the button whenever you feel the baby move.
- C. Lie flat on your back during the test.
- D. Expect contractions to occur during the test.
Correct Answer: B
Rationale: The client should press the button when fetal movements are felt, which are correlated with fetal heart rate accelerations.
What is an example of a nurse's question that is part of the Four Cs?
- A. What did you do to cause your injury?
- B. What are you concerned about today?
- C. What kind of problems will your traditions cause for other patients?
- D. When will your family move you in to stay with them?
Correct Answer: B
Rationale: The Four Cs (Concerns, Causes, Comfort, and Collaboration) focus on understanding the patient's perspective and concerns.
What is a statement about premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) that is true?
- A. PMS and PMDD affect only persons who have already reached menopause.
- B. Hormonal fluctuations are not considered potential causes of PMS and PMDD.
- C. PMS and PMDD are characterized by physical symptoms but not emotional symptoms.
- D. PMS and PMDD involve a range of physical and emotional symptoms due to fluctuating hormone levels.
Correct Answer: D
Rationale: