A nurse is assessing a newborn who was born via a forceps-assisted birth.
Which of the following findings should the nurse identify as an injury caused by the forceps?
Depressed anterior fontanel.
Uneven gluteal skinfolds.
Epicanthal folds.
Facial asymmetry.
The Correct Answer is D
Choice A rationale:
A depressed anterior fontanel is not typically caused by forceps-assisted birth. It can indicate dehydration or intracranial pressure.
Choice B rationale:
Uneven gluteal skinfolds could suggest developmental dysplasia of the hip, not a forceps injury.
Choice C rationale:
Epicanthal folds are a normal characteristic in many populations and are not related to birth injuries.
Choice D rationale:
Facial asymmetry can occur due to pressure from the forceps on the facial nerves during delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client is experiencing postpartum hemorrhage, and the nurse should first collect hemoglobin and hematocrit levels to assess the extent of blood loss.
Choice B rationale:
Inserting an indwelling urinary catheter is not the immediate priority. It may be done later to monitor fluid balance.
Choice C rationale:
Administering oxygen is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Choice D rationale:
Preparing the client to receive a plasma expander is important, but it’s not the first action. The nurse needs to assess the extent of blood loss first.
Correct Answer is B
Explanation
Choice A rationale:
The amount of amniotic fluid around the fetus is determined by an ultrasound, not an indirect Coombs’ test.
Choice B rationale:
The indirect Coombs’ test is used to detect Rh-positive antibodies in the mother’s blood.
Choice C rationale:
The risk of hypoglycemia in the newborn is not determined by the indirect Coombs’ test.
Choice D rationale:
Blood flow in the fetus and placenta is studied using Doppler ultrasound, not an indirect Coombs’ test.
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