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Patient Data

The nurse is evaluating the interventions completed by the team during the delivery.

Click to highlight the findings that would indicate that the client and/or newborn are not stable at this time.

Vacuum-assisted vaginal delivery of a viable male infant over a second- degree perineal laceration repaired under local anesthesia. There is maternal quantitative blood loss of 1,100 mL.

The newborn is attended by the neonatal team. Apgar scores are 3/4/7.

The newborn's oxygen saturation is 84%. Caput succedaneum and acrocyanosis are noted.

Vacuum-assisted vaginal delivery of a viable male infant over a second- degree perineal laceration repaired under local anesthesia.

There is maternal quantitative blood loss of 1,100 mL

Apgar scores are 3/4/7

The newborn's oxygen saturation is 84%.

Caput succedaneum and acrocyanosis are noted.

Answer and Explanation

The Correct Answer is ["B","C","D"]

Rationale for correct choices:

There is maternal quantitative blood loss of 1,100 mL: In a vaginal delivery, a blood loss exceeding 500 mL is the clinical definition of a Postpartum Hemorrhage (PPH). A loss of 1,100 mL is over double that threshold and indicates maternal hemodynamic instability, requiring immediate intervention (such as fundal massage and uterotonics).
Apgar scores are 3/4/7: Apgar scores below 7 at the 1-minute and 5-minute marks (3 and 4 in this case) indicate that the newborn is having difficulty transitioning to extrauterine life and requires active resuscitation. While the score improved to 7 by 10 minutes, the initial profound depression indicates instability.
The newborn's oxygen saturation is 84%: While neonatal oxygen saturation starts low and rises after birth, a saturation of 84% at the time of the neonatal team's assessment (following a 10-minute Apgar) is below the expected target (typically >90% by 10 minutes of age), indicating respiratory or circulatory compromise.

Rationale for incorrect answers:

Second-degree perineal laceration repaired under local anesthesia: This is a common occurrence in vacuum-assisted deliveries and, once repaired, does not inherently signify instability.
Caput succedaneum and acrocyanosis are noted: These are expected findings. Caput (swelling of the scalp) is common after vacuum-assisted births, and acrocyanosis (bluish hands/feet) is a normal finding in newborns during the first 24–48 hours of life.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Initiating seizure precautions is not indicated based on the described posturing. The client’s abnormal response to painful stimuli reflects severe neurological impairment rather than seizure activity.

B. Administering a PRN analgesic is inappropriate because the observed posturing is a neurological sign, not a pain-related behavior. Giving analgesics will not address the underlying issue.

C. Reporting the finding to the healthcare provider is the correct action. The described response—pulling the arms inward with flexion at the elbows and wrists and extending the legs with downward-pointed toes—is decorticate (arms flexed) and decerebrate (arms extended) posturing, which indicates severe brain injury or damage to the brainstem. This is a critical, time-sensitive neurological finding that requires immediate evaluation and intervention by the healthcare provider.

D. Documenting the purposeful response to pain is incorrect. The response described is not purposeful; it is abnormal posturing indicating severe neurologic compromise. Accurate documentation is important, but the urgent priority is to notify the provider.

A. Intestinal obstruction. B. Pyloric stenosis. C. Infectious gastritis. D. Abdominal peritonitis.

Correct Answer is A

Explanation

A. Intestinal obstruction is the most likely complication in a child post-Wilms tumor removal who presents with abdominal pain, distension, absent bowel sounds, and vomiting. Postoperative adhesions, bowel manipulation during surgery, or edema can impair intestinal motility, leading to obstruction. Early recognition and intervention are critical to prevent bowel ischemia or perforation.

B. Pyloric stenosis typically occurs in infants and presents with projectile vomiting, visible peristalsis, and a palpable “olive” in the abdomen. It is not a common postoperative complication in older children after abdominal tumor surgery.

C. Infectious gastritis usually presents with nausea, vomiting, and mild abdominal discomfort, but it does not typically cause absent bowel sounds or significant distension, making it less likely in this scenario.

D. Abdominal peritonitis is an inflammation of the peritoneum, often caused by perforation or infection. While it can cause severe abdominal pain and distension, it is usually associated with fever, rigidity, and severe tenderness. The gradual presentation of absent bowel sounds and vomiting aligns more closely with intestinal obstruction rather than acute peritonitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A child recovering from Wilms tumor removal develops abdominal pain, distension, absent bowel sounds, and vomiting. Which complication should the nurse suspect?

Correct Answer is A

Explanation

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