An infant is delivered with the use of forceps.
What should the nurse assess for in the newborn?
Facial asymmetry.
Sacral hematoma.
Shoulder dislocation.
Loss of hair from contact with forceps.
The Correct Answer is A
Choice A rationale
Forceps application during delivery applies pressure to the fetal head, potentially causing trauma to the facial nerve (Cranial Nerve VII) where it exits the stylomastoid foramen. This can result in Bell's palsy, characterized by unilateral facial muscle weakness or paralysis, leading to facial asymmetry, especially noticeable when the infant cries. Assessment involves observing for movement equality, symmetry of the nasolabial folds, and eyelid closure. This is a common consequence of mechanical trauma during assisted delivery.
Choice B rationale
A sacral hematoma involves a collection of blood typically associated with trauma to the sacral area, potentially from a fall or direct blunt force. While delivery can be traumatic, forceps application specifically focuses on the head for traction and rotation, making injury to the sacrum less directly linked to the instrument's primary action than facial trauma. Bruising in the sacral area might occur but a deep hematoma is not a typical forceps-specific injury.
Choice C rationale
Shoulder dislocation (or Dystocia) usually results from difficulty delivering the shoulders after the head, often due to a large fetus or a prolonged second stage. It is not a direct result of the application of obstetric forceps to the fetal skull. The primary injury concern with forceps is trauma to the head and face, whereas shoulder injuries, like a fractured clavicle or Erb's palsy, relate to excessive lateral traction on the head during delivery.
Choice D rationale
Loss of hair (alopecia) from the contact area with the forceps is a superficial effect sometimes seen, often presenting as a pressure necrosis or temporary ischemic injury to the hair follicles due to prolonged or excessive pressure. However, it is less clinically significant than potential nerve damage or soft tissue injury like facial palsy or bruising, making facial asymmetry (nerve damage) a higher priority assessment for forceps use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The absence of the enzyme hexosaminidase component A is the underlying defect in Tay-Sachs disease, a lysosomal storage disorder, not phenylketonuria (PKU). Tay-Sachs causes a buildup of GM2 ganglioside lipids in neurons, leading to progressive neurological deterioration, blindness, and spasticity, with symptoms typically presenting later than the described 5-month-old's developmental delay.
Choice B rationale
A chromosomal abnormality involving pairs 21 to 23 describes the genetic basis of Down syndrome (Trisomy 21) and other common trisomies, not PKU. Down syndrome is a set of physical and mental characteristics caused by an extra full or partial copy of chromosome 21, and its presentation is fundamentally different from the metabolic defect of PKU.
Choice C rationale
The absence of surfactant (a phospholipid-protein complex) in the lungs is the primary cause of Respiratory Distress Syndrome (RDS) in premature newborns. Surfactant reduces alveolar surface tension, preventing lung collapse. This defect is a pulmonary issue and bears no relation to the systemic metabolic disorder that affects the processing of the amino acid phenylalanine.
Choice D rationale
Phenylketonuria (PKU) is an autosomal recessive metabolic disorder caused by a deficiency of the liver enzyme phenylalanine hydroxylase (PAH). This enzyme normally converts the essential amino acid phenylalanine into tyrosine. Without adequate PAH, phenylalanine accumulates in the blood and brain, becoming toxic to the central nervous system, leading to the reported vomiting, eczema, and profound intellectual disability and developmental delay if untreated.
Correct Answer is C
Explanation
Choice A rationale
The principle of effective phototherapy is to maximize the surface area of the skin exposed to the light source, which converts unconjugated bilirubin into water-soluble photoisomers for excretion. To achieve this, the newborn's position should be changed frequently, ideally every 2 to 3 hours rather than every 4 hours, to ensure all skin surfaces are optimally illuminated.
Choice B rationale
Phototherapy increases the newborn's risk for insensible water loss due to the heat and light. To compensate and aid in the excretion of the bilirubin photoisomers, it is essential to ensure adequate hydration and feeding with milk (either breast milk or formula), not to limit it, which would exacerbate dehydration and hinder bilirubin clearance.
Choice C rationale
The high-intensity ultraviolet (UV) light used in phototherapy can cause retinal damage to the delicate, developing newborn eyes. Therefore, it is a critical safety intervention to place opaque eye shields over the newborn's closed eyes, ensuring complete coverage, and to monitor their correct placement frequently to prevent potential phototoxicity.
Choice D rationale
Applying oil-based or petroleum-based lotions to the newborn's skin is strictly contraindicated during phototherapy. These substances can absorb the light energy, causing a "tanning" effect or potentially leading to thermal burns or rashes by focusing the light intensity onto the skin, thus impairing the therapeutic effect and risking injury.
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