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 A
Explanation
Choice A rationale
Jitteriness indicates hypoglycemia in newborns as glucose is critical for neonatal brain function. Blood glucose less than 45 mg/dL supports this diagnosis, requiring prompt intervention to avoid neurological harm.
Choice B rationale
Hypertonia typically suggests central nervous system dysfunction but is not a hypoglycemia indicator. Normal newborn muscle tone ranges are neither hypertonic nor hypotonic in non-pathological states.
Choice C rationale
Acrocyanosis is common in newborns due to immature circulatory systems. It is not indicative of hypoglycemia and resolves as peripheral circulation improves.
Choice D rationale
Generalized petechiae suggest coagulation disorders or sepsis, not hypoglycemia. Petechiae warrant investigation of clotting abnormalities or infections, rather than focusing on glucose regulation.
Correct Answer is A
Explanation
Choice A rationale
Terbutaline is contraindicated in heart disease because it can cause tachycardia and arrhythmias, worsening cardiac conditions. Cardiovascular side effects result from its beta-adrenergic agonist action.
Choice B rationale
Cervical dilation of 2 cm is not a contraindication for terbutaline. The medication can be used to delay labor regardless of early cervical changes.
Choice C rationale
Gestational age of 34 weeks is not a contraindication. Terbutaline can be administered to halt preterm labor at this gestational stage if needed.
Choice D rationale
Allergy to penicillin does not contraindicate terbutaline use, as the medication belongs to a different pharmacological class and lacks cross-reactivity with penicillins.
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