The nurse is assessing an infant immediately after birth who was delivered using forceps. The nurse confirms facial paralysis.
What information would the nurse provide to the mother?
We will monitor this, but the paralysis should resolve in a few days.
The infant requires phototherapy for a few hours.
Take the newborn to a neurologist once you are discharged.
Refrain from breast-feeding the infant for a few days.
The Correct Answer is A
Choice A rationale
Facial paralysis in a newborn after a forceps delivery is most often due to trauma to the facial nerve (cranial nerve VII), typically caused by pressure from the instrument against the nerve where it exits the stylomastoid foramen. This injury is usually a temporary neuropraxia (a physiological block with intact axons) which resolves spontaneously as the swelling subsides and compression is relieved, often within a few days to a few weeks, making close monitoring appropriate.
Choice B rationale
Phototherapy is the standard treatment for neonatal hyperbilirubinemia (jaundice), a condition where unconjugated bilirubin levels are elevated (normal total bilirubin is <5 mg/dL in the first 24 hours), which is a metabolic issue. Facial paralysis is a mechanical nerve injury related to birth trauma, and therefore, phototherapy has no therapeutic effect on nerve function or paralysis resolution.
Choice C rationale
While a neurologist consultation might be needed for persistent or severe paralysis that does not begin to show signs of improvement after several weeks, initial management involves expectant monitoring. The vast majority of these injuries are mild and transient, making immediate, routine referral unnecessary and potentially causing undue parental anxiety without an immediate need for specialized intervention.
Choice D rationale
There is typically no physiological contraindication to immediate or continued breastfeeding with this type of facial nerve injury. However, the nurse should assess the infant's ability to latch and suck effectively, as paralysis might compromise the motor function required for feeding, but is not a reason to universally prohibit all attempts at breastfeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Amniotomy is the artificial rupture of membranes, a procedure to induce or augment labor. With the cervix being only 2 cm dilated and 70% effaced, the cervix is considered unfavorable, and performing an amniotomy with an unfavorable cervix may increase the risk of infection and has a higher chance of a failed induction, hence it is not the best choice.
Choice B rationale
The second stage of labor begins with complete cervical dilation (10 cm) and ends with the birth of the baby. The patient's cervix is only 2 cm dilated, indicating she is still in the latent or active phase of the first stage of labor, making this interpretation incorrect based on the current cervical assessment.
Choice C rationale
The provided assessment data focuses on cervical status and gestational age. The fetal status is not documented, thus fetal distress cannot be determined or inferred from a 2 cm dilated and 70% effaced cervix at 42 weeks' gestation. Fetal distress is identified via nonreassuring FHR patterns.
Choice D rationale
The client is a primigravida at 42 weeks' gestation with an unfavorable cervix (only 2 cm dilated and 70% effaced). The combination of post-term pregnancy and failed cervical ripening or inability to achieve adequate labor progression often leads to failed induction, for which a Cesarean birth is often the eventual anticipated outcome.
Correct Answer is B
Explanation
Choice A rationale
Amniotomy, the artificial rupture of membranes, is typically performed to induce or augment labor, especially if the membranes are intact and labor is progressing slowly. However, it carries risks such as cord prolapse, especially when the presenting part is floating (station -3 or higher), as noted, making this intervention inappropriate and potentially hazardous currently.
Choice B rationale
Early decelerations are a benign finding caused by transient fetal head compression during a contraction, mirroring the contraction shape. A floating presenting part (station greater than or equal to -3) signifies the fetal head has not yet entered the pelvic inlet, which is characteristic of the second stage of labor, or the active phase of the first stage of labor.
Choice C rationale
Early decelerations are considered a reassuring fetal heart rate pattern. Fetal distress is indicated by late or severe variable decelerations, persistent bradycardia, or absent variability, which are not present here. The FHR of 140 beats/min is within the normal range (110–160 beats/min), indicating adequate oxygenation.
Choice D rationale
A Cesarean birth is not immediately necessary. The findings—reassuring FHR pattern with early decelerations and a normal FHR of 140 beats/min—do not indicate fetal distress or an immediate maternal or fetal emergency that would necessitate urgent surgical intervention.
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