Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant?

Measuring the circumference of the infant's head

Applying a cold pack to the infant's scalp

Assessing the infant for signs of trauma

Administering prophylactic antibiotic agents to the infant

Answer and Explanation

The Correct Answer is C

After a forceps-assisted birth, the infant should be assessed for signs of trauma or injury, such as bruising, facial nerve injury, or skull fractures. This assessment should be done immediately after the birth to ensure prompt recognition and management of any issues.

Option A is incorrect because measuring the circumference of the infant's head can be done after the assessment for trauma has been completed and any issues have been addressed.
Option B is incorrect because applying a cold pack to the infant's scalp is not a standard nursing intervention after a forceps-assisted birth.
Option D is incorrect because prophylactic antibiotics are not routinely administered to infants after a forceps-assisted birth unless there is a specific indication, such as suspected infection.

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Correct Answer is C

Explanation

Nifedipine is a calcium channel blocker that can cause hypotension as a side effect, so the client should be advised to rise slowly from a sitting or lying position to avoid dizziness or fainting. The client does not necessarily need to be hospitalized and should continue taking the medication until a healthcare provider advises otherwise. The medication is typically continued until around 36-37 weeks gestation. There is no need to monitor respiratory rate with this medication.

A. Assessing fetal heart rate (FHR) and maternal vital signs B. Performing a venipuncture for hemoglobin and hematocrit levels C. Monitoring uterine contractions D. Placing clean disposable pads to collect any drainage

Correct Answer is A

Explanation

Assessing fetal heart rate (FHR) and maternal vital signs would be the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy. This is because fetal distress or maternal instability may require immediate medical intervention, such as delivery via emergency cesarean section or blood transfusions, respectively.

Therefore, assessing the FHR and maternal vital signs will help to determine the urgency of the situation and guide the next steps in the management of the patient. Once the patient's condition has stabilized, performing venipuncture for hemoglobin and hematocrit levels, monitoring uterine contractions, and placing clean disposable pads to collect any drainage can be done as appropriate.

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Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Educating a client about starting nifedipine (Procardia) for preterm labor prevention, the nurse knows that her educational plan for this client should include which of the following?

Correct Answer is C

Explanation

What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?

Correct Answer is A

Explanation

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