A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor.
The nurse would be alert for which of the following in the newborn?
Caput succedaneum.
Central nervous system injury.
Asphyxia.
Clavicular fracture.
The Correct Answer is A
Choice A rationale
The application of a vacuum extractor cup creates negative pressure on the fetal scalp, specifically aiming to assist in delivery. A common and expected consequence of this suction is the formation of a caput succedaneum, which is a localized edematous swelling (serosanguinous fluid) of the soft tissues of the scalp, located above the periosteum. It is typically present at birth and crosses suture lines.
Choice B rationale
While severe, prolonged vacuum extraction or misuse can rarely lead to serious complications, central nervous system injury (e.g., intracranial hemorrhage) is not the most common or expected adverse effect. The nurse's initial alert should be for the most frequent and less severe, yet common, physiological responses to the procedure, such as scalp trauma.
Choice C rationale
Asphyxia (impaired gas exchange leading to hypoxemia and hypercapnia) is a complication that may necessitate the use of a vacuum extractor but is not a direct or most common result of the device's application. The procedure is intended to prevent or alleviate a prolonged labor that could lead to asphyxia.
Choice D rationale
Clavicular fracture is more commonly associated with shoulder dystocia or a difficult, manual breech delivery where lateral traction is applied to the baby's head or neck. While vacuum extraction carries risks, a clavicular fracture is not the typical or most anticipated trauma directly resulting from the suction on the scalp.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Post-term pregnancy, defined as a gestation extending past 42 weeks, is a valid indication for oxytocin induction. This is because the risk of placental insufficiency, fetal macrosomia, oligohydramnios, and subsequent fetal distress or stillbirth increases significantly after the estimated due date has passed the 42-week mark.
Choice B rationale
Polyhydramnios, an excess of amniotic fluid, is not a standard indication for oxytocin induction; it is often associated with conditions like gestational diabetes or fetal anomalies. While it can cause maternal discomfort or uterine overdistension, induction is usually only necessary if associated complications threaten maternal or fetal well-being.
Choice C rationale
A history of long labors is a retrospective observation, not a medical indication for the induction of labor in the current pregnancy. Labor induction is based on current maternal or fetal health risks, not prior labor patterns. Oxytocin induction itself carries risks, and a prior long labor does not necessitate intervention this time.
Choice D rationale
Multiple fetuses (e.g., twins) is not an acceptable indication for routine oxytocin induction and often presents a relative contraindication. Multiple gestations carry a higher risk of complications like preterm labor and uterine overdistension, and labor management often requires careful monitoring, sometimes leading to a Cesarean section.
Correct Answer is C
Explanation
Choice A rationale
Confirming the mother's room number is a basic safety and logistical measure, but it does not provide definitive, legally verifiable identification to link the specific infant to the correct mother. The primary safeguard against infant abduction or accidental mix-up is the unique, unalterable identification system applied immediately after birth, which is the comparison of corresponding numbered bands, ensuring the identity match.
Choice B rationale
Asking the mother, "Is this your band number?", is an inappropriate leading question that could elicit an incorrect, affirmative response, compromising security. The nurse must independently verify the match between the numbered band on the infant and the corresponding numbered band on the mother (or a significant other), ensuring that the unique identifying codes are identical before transferring custody.
Choice C rationale
The comparison of the band number of the infant with that of the mother is the most critical and non-negotiable step for security. Identification bands, applied in the delivery room, bear matching, unique numbers and are the primary system of positive identification. This check ensures that the specific infant being transported is biologically and legally linked to the specific mother, thereby preventing accidental mix-ups or abductions.
Choice D rationale
Asking the mother to verbally identify herself (e.g., state her full name) helps confirm the identity of the person receiving the infant but is not sufficient for infant security. Verbal identification is easily compromised and does not verify the infant's identity. The essential security measure remains the visual and numerical comparison of the infant's and mother's matching identification band numbers.
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.