After a birth complicated by a shoulder dystocia, the infant’s Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously.
What should the nurse in the birthing room do?
Palpate the infant’s clavicles
Encourage the parents to hold the infant
Perform a complete newborn assessment
Give supplemental oxygen with a small face mask
The Correct Answer is A
Choice A rationale
After a birth complicated by shoulder dystocia, it is important to palpate the infant’s clavicles. This is because shoulder dystocia can lead to a clavicle fracture.
Choice B rationale
While encouraging the parents to hold the infant is generally a good practice, it is not the immediate action to take after a birth complicated by shoulder dystocia.
Choice C rationale
A complete newborn assessment is important, but the immediate action after a birth complicated by shoulder dystocia is to check for any injuries related to the difficult birth.
Choice D rationale
Giving supplemental oxygen is not the immediate action to take after a birth complicated by shoulder dystocia unless the baby shows signs of respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Sporadic vaginal bleeding accompanied by chronic pelvic pain is not typically associated with a woman who has had multiple pregnancies and is admitted for repair of cystocele and rectocele.
Choice B rationale
Heavy leukorrhea with vulvar pruritus is not typically associated with a woman who has had multiple pregnancies and is admitted for repair of cystocele and rectocele.
Choice C rationale
Menstrual irregularities and hirsutism on the chin are not typically associated with a woman who has had multiple pregnancies and is admitted for repair of cystocele and rectocele.
Choice D rationale
Stress incontinence with a feeling of low abdominal pressure is a common symptom in women who have had multiple pregnancies and are admitted for repair of cystocele and rectocele. Multiple pregnancies can weaken the pelvic floor muscles, leading to conditions like cystocele and rectocele. Stress incontinence, where urine leaks out with increased abdominal pressure (such as when coughing, sneezing, or lifting), is a common symptom of these conditions.
Correct Answer is B
Explanation
Choice A rationale
Notifying the clinician immediately may be necessary, but it is not the first action to take. The nurse should first identify the cause of the baby’s symptoms.
Choice B rationale
The baby’s symptoms are indicative of hypoglycemia, a common condition in infants of mothers with diabetes. Testing the blood glucose level would confirm this diagnosis and allow for appropriate treatment.
Choice C rationale
Starting an intravenous line with D5W may be necessary if the baby’s blood glucose level is low. However, the first step should be to confirm the diagnosis by testing the blood glucose level.
Choice D rationale
Documenting the event in the nurse’s notes is important, but it is not the first action to take. The nurse should first address the baby’s immediate needs.
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