Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant?

Measuring the circumference of the infant's head

Applying a cold pack to the infant's scalp

Assessing the infant for signs of trauma

Administering prophylactic antibiotic agents to the infant

Answer and Explanation

The Correct Answer is C

After a forceps-assisted birth, the infant should be assessed for signs of trauma or injury, such as bruising, facial nerve injury, or skull fractures. This assessment should be done immediately after the birth to ensure prompt recognition and management of any issues.

Option A is incorrect because measuring the circumference of the infant's head can be done after the assessment for trauma has been completed and any issues have been addressed.
Option B is incorrect because applying a cold pack to the infant's scalp is not a standard nursing intervention after a forceps-assisted birth.
Option D is incorrect because prophylactic antibiotics are not routinely administered to infants after a forceps-assisted birth unless there is a specific indication, such as suspected infection.

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Correct Answer is C

Explanation

The nurse recognizes that a nonstress test (NST) in which two or more fetal heart rate (FHR) accelerations of 15 beats/min or more occur with fetal movement in a 20-minute period is considered reactive. A reactive NST is a reassuring sign of fetal well-being and indicates that the fetal nervous system and cardiovascular system are intact and functioning appropriately. If a reactive NST is not obtained, further testing or evaluation may be necessary to assess fetal well-being.

A. Administration of steroids B. Administration of blood C. Restriction of intravascular fluids D. Preparation of the client for invasive hemodynamic monitoring

Correct Answer is B

Explanation

In DIC, there is widespread clotting that can lead to depletion of clotting factors and platelets, resulting in bleeding. The priority in the care of DIC is to correct the underlying cause and to replace lost blood products to prevent hypovolemia and hemorrhage. Therefore, the nurse should anticipate an order for the administration of blood products such as packed red blood cells, fresh frozen plasma, and platelets. Administration of steroids may also be ordered to reduce inflammation and stabilize cell membranes. Restriction of intravascular fluids may be necessary to prevent further bleeding, but it is not the first priority. Invasive hemodynamic monitoring may be used to assess the client's fluid and electrolyte status, but it is not typically the first intervention.

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Which nursing intervention should be immediately performed after the forceps-assisted birth of an infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes that a nonstress test (NST) in which two or more fetal heart rate (FHR) accelerations of 15 beats/min or more occur with fetal movement in a 20-minute period is:

Correct Answer is C

Explanation

In caring for the woman with disseminated intravascular coagulation (DIC), which order should the nurse anticipate?

Correct Answer is B

Explanation

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