A nurse is conducting an initial assessment of a newborn delivered with a nuchal cord. What clinical findings should the nurse anticipate?
Facial petechiae
Erythema toxicum
Periauricular papillomas
Telangiectatic nevi
The Correct Answer is A
Choice A rationale
Facial petechiae are small, pinpoint, red or purple spots on the skin that can occur when a newborn has a nuchal cord, or the umbilical cord wrapped around the neck. This is due to the pressure exerted on the baby’s face and neck during delivery.
Choice B rationale
Erythema toxicum is a common rash seen in newborns, characterized by tiny bumps surrounded by red skin. However, it is not specifically associated with a nuchal cord.
Choice C rationale
Periauricular papillomas are small skin tags or pits seen near the ear. They are a common minor anomaly seen in newborns, but they are not associated with a nuchal cord.
Choice D rationale
Telangiectatic nevi, also known as “stork bites,” are common birthmarks seen in newborns, characterized by small, light pink patches, usually on the back of the neck. However, they are not associated with a nuchal cord.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying a moist, warm compress to the perineum is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum.
Choice B rationale
Administering methylergonovine 0.2 mg IM is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Methylergonovine is a medication used to prevent or control bleeding of the uterus following childbirth or abortion.
Choice C rationale
Providing the client with a cool sitz bath is the correct action. A sitz bath can help to soothe the perineal area, reduce inflammation, and promote healing.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery.
Correct Answer is C
Explanation
Choice A rationale
Massaging the client’s fundus is not indicated in this situation. Fundal massage is typically done after childbirth to help the uterus contract and prevent excessive bleeding.
Choice B rationale
Applying oxygen can help increase the client’s oxygen saturation levels, but it does not directly address the cause of the hypotension.
Choice C rationale
Turning the client to a side-lying position, specifically the left lateral position, can help improve blood flow to the heart, increasing cardiac output and blood pressure.
Choice D rationale
Assisting the client to empty their bladder is important in postpartum care, but it is not the immediate action to take when a client is hypotensive following the administration of epidural anesthesia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.