A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?
Poor sucking.
Blue coloring of the hands and feet.
Soft, edematous area on the scalp.
Facial edema.
The Correct Answer is A
Choice A rationale:
This finding may indicate a neurological problem or an issue with the baby's ability to feed, which can lead to inadequate nutrition and hydration. It's essential for the newborn to establish good feeding patterns early on
Choice B rationale:
Blue coloring of the hands and feet, also known as acrocyanosis, is a common and normal finding in newborns. It results from the immaturity of the peripheral circulation and usually resolves on its own without any intervention.
Choice C rationale:
A soft, edematous area on the scalp, also known as caput succedaneum, is a common finding following vacuum-assisted delivery and typically resolves without intervention.
Choice D rationale:
Facial edema is another common finding in newborns, especially after vacuum-assisted deliveries. It is typically a transient and self-resolving condition that does not require immediate intervention or reporting to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Choice B reason:
Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.
Choice C reason:
Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.
Choice D reason:
This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Correct Answer is A
Explanation
Choice A rationale:
When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.
Choice B rationale:
Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.
Choice C rationale:
Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.
Choice D rationale:
Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.
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