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 this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted births can put pressure on the baby's face, leading to facial nerve injury and subsequent facial palsy. This can result in weakness or paralysis of facial muscles. Polycythemia (choice A) is not typically associated with forceps-assisted births. Hypoglycemia (choice B) may occur in newborns for various reasons, but it is not directly related to the birth method. Bronchopulmonary dysplasia (choice C) is a lung condition usually seen in premature infants, not specifically linked to forceps deliveries. In summary, facial palsy is the most likely complication of forceps-assisted births due to the pressure exerted on the baby's face during the delivery process.
You may also like to solve these questions
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways
- B. Places the newborn in the crib in a prone position
- C. Offers the newborn a pacifier dipped in formula
- D. Prepares a bottle of formula mixed with rice cereal
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps provide comfort and bonding, mimicking the soothing motion in the womb. This action promotes a secure attachment between the guardian and the newborn. Placing the newborn in a crib in a prone position (B) is unsafe and increases the risk of sudden infant death syndrome (SIDS). Offering a pacifier dipped in formula (C) can introduce unnecessary calories and increase the risk of overfeeding. Preparing a bottle of formula mixed with rice cereal (D) is not appropriate for a newborn and can lead to digestive issues.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Assessing the newborn's latch while breastfeeding is crucial in addressing sore nipples. A poor latch can lead to nipple pain. By ensuring proper latch, the nurse can help alleviate the client's discomfort. Other actions are incorrect:
A: Waiting 4 hr between feedings can lead to engorgement and worsen nipple soreness.
C: Limiting breastfeeding time to 5 min can hinder milk supply and not address the root cause.
D: Offering supplemental formula can interfere with establishing breastfeeding and may not address the latch issue.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels as hypoglycemia is a common cause. Low blood glucose in a newborn can lead to seizures and long-term neurological damage. Monitoring blood glucose levels and promptly addressing any abnormalities is crucial. Total bilirubin (B) is important for assessing jaundice, not jitteriness. Hemoglobin (C) and blood calcium (D) are not typically related to jitteriness in a newborn.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling
- B. Amnioinfusion
- C. Biophysical profile (BPP)
- D. Chorionic villus sampling (CVS)
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). This test evaluates the fetus's well-being by assessing fetal heart rate, fetal breathing movements, fetal movement, fetal tone, and the volume of amniotic fluid. In a client at 41 weeks with a positive contraction stress test, a BPP helps determine if immediate delivery is necessary due to potential fetal distress.
Percutaneous umbilical blood sampling (A) is used to directly sample fetal blood and assess fetal oxygenation but is not typically indicated in this scenario. Amnioinfusion (B) is used to relieve variable decelerations during labor by infusing sterile fluid into the amniotic cavity, which is not relevant to a client at 41 weeks of gestation with a positive contraction stress test. Chorionic villus sampling (D) is an invasive procedure to diagnose genetic abnormalities early in pregnancy and is not indicated for assessing fetal well-being at 41 weeks.