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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Applying firm pressure on the client’s suprapubic area is not part of the McRoberts maneuver. This action is more associated with the suprapubic pressure technique, which is another method used to manage shoulder dystocia.
Choice B rationale
The McRoberts maneuver involves having the client flex her hips against her abdomen. This is achieved by assisting the client in pulling her knees toward her abdomen.
Choice C rationale
Applying pressure to the client’s fundus is not part of the McRoberts maneuver and can be contraindicated as it may cause additional complications.
Choice D rationale
Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position is more associated with the all-fours maneuver, also known as the Gaskin maneuver.
Correct Answer is D
Explanation
The correct answer is choice d. Assist the client to the bathroom.
Choice A rationale:
Inserting a urinary catheter is an invasive procedure and should be considered only after less invasive measures have been attempted and failed. It carries risks such as infection and trauma to the urethra.
Choice B rationale:
Pouring warm water over the client’s perineum can help stimulate urination, but it should be tried after assisting the client to the bathroom. It is a non-invasive method but not the first action to take.
Choice C rationale:
Offering a sitz bath can also help with urination by relaxing the perineal muscles, but it is not the first action to take. It is more appropriate if the client is unable to void after trying to use the bathroom.
Choice D rationale:
Assisting the client to the bathroom is the least invasive and most straightforward initial action. It allows the client to attempt to void naturally, which is preferable before trying other interventions.
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