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
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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Related Questions
Correct Answer is C
Explanation
This is because magnesium sulfate can cause respiratory depression, and a respiratory rate of 10 breaths/minute is significantly lower than the normal range of 12-20 breaths/minute. Other factors such as blood pressure of 138/88, the urinary output of 40 ml/hr, and patellar reflex of +2 should also be monitored, but they would not necessarily warrant immediate discontinuation of the magnesium sulfate infusion.
Correct Answer is B
Explanation
Caput succedaneum is a common condition in newborns that causes swelling of the soft tissues of the scalp. It is usually caused by pressure on the baby's head during delivery and can be seen in both vaginal and instrumental births, such as vacuum-assisted deliveries. It generally crosses the suture lines, unlike a cephalohematoma.
Caput succedaneum is not a serious condition and generally resolves on its own within a few days without any treatment. However, the nurse should continue to monitor the newborn for signs of jaundice, which can occur due to the breakdown of red blood cells in the swelling.
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