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 nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10. The child has just returned to the unit after a computed tomography (CT) scan of the abdomen and tells the nurse the pain just stopped. Which of the following should the nurse do first?
- A. "The illness requires careful attention to fluid balance since hyperglycemia contributes to dehydration."'
- B. "Exercise requires additional insulin since glucose will be released from the cells during activity."'
- C. "Urine glucose must be monitored because there is a correlation between simultaneous glycosuria and blood glucose concentrations."'
- D. "The diet needs to include fewer complex carbohydrates because they quickly raise blood glucose."'
Correct Answer: A
Rationale: The correct answer is A because in this scenario, the child's sudden relief from pain after a CT scan could indicate a possible rupture of the appendix. This is a critical situation that requires immediate attention to prevent complications such as peritonitis. Monitoring fluid balance is crucial to prevent dehydration, especially if surgery is needed. Choices B, C, and D are incorrect and not the priority as they focus on managing diabetes, which is not the primary concern in this case. Monitoring glucose levels, adjusting insulin, or modifying the diet are not immediate actions required for a child with suspected appendicitis.
With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy?
- A. You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar.
- B. Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby.
- C. There is a good possibility you will be taking insulin for the rest of your life.
- D. You should eat three large meals per day to maintain steady glucose load.
Correct Answer: B
Rationale: The correct answer is B: Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs of the baby. During pregnancy, the placenta produces hormones that can make it difficult for insulin to work effectively, leading to gestational diabetes. Insulin helps to lower blood sugar levels in the mother, which in turn provides the necessary glucose for the developing baby's growth and development. The other choices are incorrect because: A) Oral hypoglycemics are not typically prescribed during pregnancy due to potential risks to the baby. C) Gestational diabetes usually resolves after delivery and does not require lifelong insulin use. D) Eating three large meals per day can cause blood sugar spikes and is not recommended for managing gestational diabetes.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
During the active phase of labor, the membranes rupture and the nurse notes green amniotic fluid. Which nursing action should be initiated immediately?
- A. Call the physician.
- B. Replace the soiled underpad.
- C. Test the fluid with pH (Nitrazine) paper.
- D. Assess fetal heart rate.
Correct Answer: D
Rationale: The correct answer is D: Assess fetal heart rate. This is important because green amniotic fluid indicates meconium staining, which can be a sign of fetal distress. Assessing the fetal heart rate immediately will help determine the baby's well-being. Calling the physician (choice A) may be necessary but assessing the fetal heart rate should be the priority. Replacing the underpad (choice B) can wait until after assessing the fetal heart rate. Testing the fluid with pH paper (choice C) may confirm the presence of meconium but assessing the fetal heart rate is more urgent.
The parents of a 4-year-old child state that they had an infant die 2 months ago during childbirth.
- A. "Our child wants to go to the cemetery to be with his sister."'
- B. "Our child asks many questions about what happened to the baby's body."'
- C. "Our child is not sleeping,eating or playing lately and we are worried."'
- D. "Our child blames himself for the baby's death because he said he didn't want a baby brother or sister."'
Correct Answer: D
Rationale: The correct answer is D because it reflects a common behavior in children who have experienced a loss - feeling guilty or blaming themselves for the death. This is known as magical thinking, where children associate their thoughts or actions with causing events. Choice A may indicate a desire for connection but doesn't directly address the child's internal struggle with guilt. Choice B shows curiosity but doesn't address the emotional impact on the child. Choice C highlights concerning behaviors but doesn't capture the underlying psychological issue of guilt. Overall, D is the best choice as it directly addresses the child's emotional response to the loss.