Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?
a. Assess the infant for signs of trauma.
b. Apply a cold pack to the infant's scalp.
c. Give the infant prophylactic antibiotics.
d. Measure the circumference of the infant's head.
ANS: A
Forceps birth can result in local irritation, bruising, or lacerations of the fetal scalp. This would put the infant at risk for cold stress and would be contraindicated. Prophylactic antibiotics are not necessary with a forceps birth. Measuring the circumference of the head is part of the initial nursing assessment.
You might also like to view...
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.
A woman is having a planned cesarean birth. The nurse explains to the student that which of the following would not be an appropriate choice of anesthesia for this woman?
A. Epidural block B. General anesthesia C. Pudendal block D. Spinal block
A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit
The nurse should be aware that the treatment of choice for this patient is what? A) IV administration of immune globulins B) Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C) Liver transplantation D) Lobectomy
At which point in the physical examination should the nurse assess a patient's vital signs?
A) After the integumentary status examination B) After the cardiovascular system examination C) After the respiratory system examination D) After the body measurements examination