Nursing Elites

1. A newborn is being assessed following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method?

• A. Hypoglycemia
• B. Polycythemia
• C. Facial Palsy
• D. Bronchopulmonary dysplasia

Correct answer: C

Rationale: Facial palsy is a known complication of forceps-assisted birth. During forceps delivery, pressure applied to the facial nerve can result in facial palsy. The newborn may present with weakness or paralysis of the facial muscles on one side. Hypoglycemia (Choice A) is not directly related to forceps-assisted birth. Polycythemia (Choice B) is a condition characterized by an increased number of red blood cells and is not typically associated with forceps delivery. Bronchopulmonary dysplasia (Choice D) is a lung condition that primarily affects premature infants who require mechanical ventilation and prolonged oxygen therapy, not a direct outcome of forceps-assisted birth.

2. The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse document in the medical record?

• A. Caput succedaneum
• B. Hydrocephalus
• C. Cephalhematoma
• D. Microcephaly

Correct answer: C

Rationale: The correct answer is Cephalhematoma. Cephalhematoma is a collection of blood between the skull bone and periosteum that does not cross the suture line. It often occurs due to birth trauma, such as forceps delivery, leading to localized swelling. Caput succedaneum (Choice A) is diffuse swelling of the scalp that may cross suture lines and is typically present at birth. Hydrocephalus (Choice B) is an abnormal accumulation of cerebrospinal fluid within the brain's ventricles. Microcephaly (Choice D) is a condition characterized by a smaller than average head size and may be present at birth or develop later in infancy.

3. Which of the following illnesses causes degeneration of the central nervous system?

• A. Tay-Sachs disease
• B. Cystic fibrosis
• C. Turner syndrome
• D. Klinefelter syndrome

Correct answer: A

Rationale: Tay-Sachs disease is a genetic disorder that causes a progressive degeneration of the central nervous system, particularly in infants. Choice B, Cystic fibrosis, is a genetic disorder that primarily affects the lungs and digestive system, not the central nervous system. Choices C and D, Turner syndrome and Klinefelter syndrome, are chromosomal disorders that do not directly involve degeneration of the central nervous system.

4. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

• A. A client with a urinary output of 300 ml in 8 hours
• B. A client reporting abdominal cramping during breastfeeding
• C. A client receiving magnesium sulfate with absent deep tendon reflexes
• D. A client reporting lochia rubra requiring changing perineal pads every 3 hours

Correct answer: C

Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.

5. During the client’s initial prenatal visit, which of the following would indicate a need for further assessment?

• A. History of diabetes for 6 years.
• B. Exercises three times a week.
• C. Occasional use of over-the-counter pain relievers.
• D. Maternal age 30 years.

Correct answer: A

Rationale: A history of diabetes for 6 years indicates a pre-existing medical condition that can significantly impact both the mother and the developing fetus during pregnancy. This necessitates further assessment and monitoring to manage potential complications. Regular exercise (Choice B) is generally beneficial during pregnancy and does not raise immediate concerns. Occasional use of over-the-counter pain relievers (Choice C) is common and does not necessarily indicate a need for further assessment during the initial visit. Maternal age of 30 years (Choice D) falls within the normal range for childbearing and is not a standalone factor requiring immediate further assessment.

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