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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Bronchopulmonary dysplasia is a chronic lung disease that affects newborns and infants, but it is not a complication of forceps-assisted birth. It’s more common in premature babies who have been treated with oxygen and positive-pressure ventilation.
Choice B rationale
Polycythemia, a condition characterized by an increased number of red blood cells, is not a complication of forceps-assisted birth. It can occur due to various reasons, including high altitude and certain genetic disorders.
Choice C rationale
Facial palsy can occur as a complication of forceps-assisted birth. The pressure exerted by the forceps can cause damage to the facial nerve, leading to temporary or permanent facial weakness or paralysis.
Choice D rationale
Hypoglycemia, or low blood sugar, is not a complication of forceps-assisted birth. It’s more commonly seen in babies of mothers with diabetes, premature babies, and babies who are small for their gestational age.

A. Provide the patient with photos of the fetus. B. Instruct the patient that an autopsy should be performed within 24 hours. C. Limit the amount of time the fetus is in the patient’s room. D. Inform the patient that the law requires them to name the fetus.

Correct Answer is A

Explanation

Choice A rationale
Providing the patient with photos of the fetus can be a part of memory-making and is often a key component of care after a stillbirth. It allows parents to remember their baby and can aid in the grieving process.
Choice B rationale
While an autopsy can provide information about why a stillbirth occurred, it is not mandatory and should be discussed with the parents. The decision to perform an autopsy should be based on the parents’ wishes.
Choice C rationale
Limiting the amount of time the fetus is in the patient’s room is not necessarily beneficial. Some parents may want to spend time with their baby to say goodbye, which can be therapeutic.
Choice D rationale
Informing the patient that the law requires them to name the fetus is not accurate. The decision to name the fetus is a personal one and varies among individuals.

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A nurse is conducting an initial assessment of a newborn delivered with a nuchal cord. What clinical findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?

Correct Answer is C

Explanation

A nurse is caring for a patient immediately following the delivery of a stillborn fetus. What action should the nurse take?

Correct Answer is A

Explanation

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