Nokea
The parents of a newborn ask the nurse what caused the babys facial nerve paralysis. The nurses response is based on remembering that this is caused by what?
- A. Birth injury
- B. Genetic defect
- C. Spinal cord injury
- D. Inborn error of metabolism
Correct Answer: A
Rationale: Pressure on the facial nerve (cranial nerve VII) during delivery may result in injury to the nerve. Genetic defects, spinal cord injuries, and inborn errors of metabolism did not cause the facial nerve paralysis. The paralysis usually disappears in a few days but may take as long as several months.
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The nurse is caring for a newborn with Erb palsy. The nurse understands that which reflex is absent with this condition?
- A. Root reflex
- B. Suck reflex
- C. Grasp reflex
- D. Moro reflex
Correct Answer: D
Rationale: Erb palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus and usually results from stretching or pulling away of the shoulder from the head. The Moro reflex is absent in a newborn with Erb palsy. The root and suck reflex are not affected. A grasp reflex is present in newborns because the finger and wrist movements remain normal.
A woman who is Rh-negative is pregnant with her first child, and her husband is Rh positive. During her 12-week prenatal visit, she tells the nurse that she has been told that this is dangerous. What should the nurse tell her?
- A. That no treatment is necessary
- B. That an exchange transfusion will be necessary at birth
- C. That no treatment is available until the infant is born
- D. That administration of Rh immunoglobulin is indicated at 26 to 28 weeks of gestation
Correct Answer: D
Rationale: The goal is to prevent isoimmunization. If the mother has not been previously exposed to the Rh-negative antigen, Rh immunoglobulin (RhIg) is administered at 26 to 28 weeks of gestation and again within 72 hours of birth. The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the infant secondary to the Rh factor. Unless other problems coexist, the newborn will not require transfusions at birth.
A pregnant client asks the nurse to explain the meaning of cephalopelvic disproportion. Which explanation should the nurse give to the client?
- A. It means a large for gestational age fetus.
- B. It is the narrow opening between the ischial spines.
- C. There is an uneven size between the fetus presenting part and the pelvis.
- D. The shape of the pelvis is an android shape and is unfavorable for vaginal delivery.
Correct Answer: C
Rationale: Cephalopelvic disproportion means a disproportion (or uneven size) between the fetus presenting part and the maternal pelvis. It does not mean a large for gestational age fetus or that the pelvis is an android shape. The narrow opening between the ischial spines is called the transverse measurement.
What is an infant with severe jaundice at risk for developing?
- A. Encephalopathy
- B. Bullous impetigo
- C. Respiratory distress
- D. Blood incompatibility
Correct Answer: A
Rationale: Unconjugated bilirubin, which can cross the blood-brain barrier, is highly toxic to neurons. An infant with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Bullous impetigo is a highly infectious bacterial infection of the skin. It has no relation to severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice.
Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
- A. Hydrocephalus
- B. Cephalhematoma
- C. Caput succedaneum
- D. Subdural hematoma
Correct Answer: C
Rationale: Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. The swelling consists of serum or blood (or both) accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It should not be visible on the scalp.