Nokea
What should the nurse assess for in the newborn?
- A. Loss of hair from contact with forceps
- B. Sacral hematoma
- C. Facial asymmetry
- D. Shoulder dislocation
Correct Answer: C
Rationale: Pressure from forceps may injure the infant's facial nerve, which is evidenced by facial asymmetry.
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What complication should the nurse closely assess for with this patient?
- A. Chorioamnionitis
- B. Hemorrhage
- C. Hypotension
- D. Amniotic fluid embolism
Correct Answer: A
Rationale: Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture, because the barrier to the uterine cavity is broken.
What will the nurse include in the educational plan?
- A. Onset is slow.
- B. Duration is short.
- C. Administration is by mouth.
- D. No known side effects.
- E. It is not the same drug as sufentanil.
Correct Answer: B,E
Rationale: Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are distinct drugs. Fentanyl can cause respiratory depression but less than meperidine and is not administered by mouth.
How would the nurse position the woman to prevent compression of a prolapsed cord?
- A. On her right side with knees flexed
- B. On her left side with a pillow placed between her legs
- C. On her back with her head lower than the rest of her body
- D. Supine with her legs elevated and bent at the knee
Correct Answer: C
Rationale: The Trendelenburg's (head down) position displaces the fetus upward to stop compression of the prolapsed cord.
Which laboring patient should the nurse attend to first?
- A. 18-year-old primigravida with a fetal breech presentation
- B. 25-year-old multigravida with history of previous cesarean section
- C. 35-year-old multigravida with history of precipitate birth
- D. 16-year-old primigravida with a twin pregnancy
Correct Answer: C
Rationale: A precipitate birth is completed in less than 3 hours and can lead to complications like uterine rupture or cervical lacerations, requiring immediate attention.
Which interventions could a nurse apply to help stimulate contractions?
- A. Encouraging the patient to sit upright
- B. Assisting the patient to ambulate
- C. Stimulating the nipples
- D. Offering emotional support
- E. Allowing the patient to vent frustration
Correct Answer: A,B,C
Rationale: Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor.