Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy.
What additional care should the nurse consider?
Administering prophylactic antibiotics to prevent infection.
Assessing for signs of jaundice in the newborn.
Monitoring the client's vital signs for stability.
Educating the client on breastfeeding techniques.
The Correct Answer is B
Choice A rationale
Administering prophylactic antibiotics is essential when there is infection risk, but this intervention is not directly related to managing hemorrhage or neonatal nerve palsy.
Choice B rationale
Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.
Choice C rationale
Monitoring vital signs ensures maternal stability, though it does not directly address hemorrhage risk or neonatal complications like nerve palsy.
Choice D rationale
Educating the client on breastfeeding techniques provides essential support but does not focus on managing cephalohematoma-related neonatal conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hypothyroidism is associated with certain conditions like iodine deficiency, but it is not a primary risk in the described situation. It does not specifically link to the immediate complications presented here.
Choice B rationale
Fallopian tube rupture is a critical complication of conditions like ectopic pregnancy, emphasizing the importance of timely diagnosis and intervention to prevent life-threatening internal bleeding and sepsis.
Choice C rationale
Hypovolemic shock, while life-threatening, is a secondary complication arising from severe conditions like abrupt rupture or hemorrhage. It is crucial but not as directly relevant as addressing fallopian tube rupture.
Choice D rationale
An invasive mole is a concern in certain pregnancies, especially following molar pregnancies, but the scenario here does not predominantly highlight invasive mole development.
Correct Answer is B
Explanation
Choice A rationale
Intravenous medications are not administered for a nonstress test, which evaluates fetal heart rate response to movement using external monitoring. No pharmacological intervention is needed.
Choice B rationale
Nonstress tests typically last about 20–40 minutes, depending on fetal activity and reactivity. This duration allows sufficient time to observe fetal heart rate accelerations.
Choice C rationale
There are no dietary restrictions for a nonstress test, as the procedure involves non-invasive external monitoring and does not affect digestion or metabolic processes.
Choice D rationale
A nonstress test does not assess fetal lung maturity but evaluates fetal heart rate accelerations in response to fetal movement to ensure fetal well-being.
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