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.

Answer and Explanation

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.

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Correct Answer is E

Explanation

Choice A rationale

No acute distress indicates the client's physiological stability. It reflects an absence of acute systemic responses like tachycardia or labored breathing, suggesting normal homeostasis during examination.

Choice B rationale

No cardiovascular murmurs or rubs imply normal valve function and an absence of pericardial inflammation. This finding indicates no pathological blood flow changes or cardiac friction sounds.

Choice C rationale

Clear bilateral breath sounds suggest open airways and proper ventilation, excluding lower respiratory tract issues like pneumonia. Normal respiratory examination confirms adequate pulmonary function.

Choice D rationale

Fundal height at 38 cm corresponds to late-third trimester pregnancy. It reflects uterine enlargement due to fetal growth, indicating gestational progression but unrelated to cervical discharge.

Choice E rationale

Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.

A. Low uterine tone with mild vaginal bleeding. B. Rigid uterine tone with dark vaginal bleeding. C. Soft uterine tone with painless vaginal bleeding. D. Low uterine tone with absence of vaginal bleeding.

Correct Answer is B

Explanation

Choice A rationale: Low uterine tone with mild vaginal bleeding is more indicative of placenta previa rather than abruptio placenta. Placenta previa involves the placenta covering the cervix, leading to painless bleeding. Uterine tone remains soft as there is no detachment of the placenta from the uterine wall. Abruptio placenta, however, is characterized by uterine rigidity due to blood accumulation between the placenta and uterine wall.

Choice B rationale: Rigid uterine tone with dark vaginal bleeding is a hallmark of abruptio placenta. The rigidity arises from blood pooling behind the placenta, causing uterine muscle contraction. Dark vaginal bleeding occurs as the blood is often concealed and clotted before expulsion. This condition is a medical emergency due to the risk of maternal hemorrhage and fetal hypoxia. Prompt diagnosis and intervention are critical to prevent severe complications.

Choice C rationale: Soft uterine tone with painless vaginal bleeding is characteristic of placenta previa, not abruptio placenta. Placenta previa involves the placenta partially or completely covering the cervix, leading to painless bleeding as the placenta detaches from the lower uterine segment. The uterine tone remains soft because there is no significant blood accumulation or uterine muscle contraction, unlike in abruptio placenta.

Choice D rationale: Low uterine tone with absence of vaginal bleeding does not align with abruptio placenta. While concealed abruptio placenta can occur without visible bleeding, the uterine tone is typically rigid due to blood accumulation. Low uterine tone suggests a lack of uterine contraction or detachment, which is inconsistent with the pathophysiology of abruptio placenta. This finding may indicate other obstetric conditions rather than abruptio placenta.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is E

Explanation

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Correct Answer is B

Explanation

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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?