Final Exam Pedi Eves - Greater Lowell Technical School
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Free Final Exam Pedi Eves - Greater Lowell Technical School Questions
1. The nurse educates prenatal patients about the threat of TORCH infections. These infections include: (Select all that apply.)
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Toxoplasmosis
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Toxemia
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Cytomegalovirus
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Rubella
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Herpes simplex
Explanation
Explanation
Correct Answer: (A) Toxoplasmosis, (C) Cytomegalovirus, (D) Rubella, and (E) Herpes simplex.
TORCH is an acronym that represents a group of infections capable of crossing the placenta and causing serious harm to the developing fetus. T stands for Toxoplasmosis, O for Other infections such as syphilis and varicella, R for Rubella, C for Cytomegalovirus, and H for Herpes simplex. All four of these options are components of or fall within the TORCH classification and pose significant teratogenic and neonatal risks.
Why the other options are incorrect:
B. Toxemia — Toxemia is an outdated term for preeclampsia, which is a hypertensive disorder of pregnancy. It is not an infectious condition and has no place in the TORCH acronym. It is unrelated to the group of congenital infections the TORCH framework addresses.
Correct Answer: (A) Toxoplasmosis, (C) Cytomegalovirus, (D) Rubella, and (E) Herpes simplex.
TORCH is an acronym that represents a group of infections capable of crossing the placenta and causing serious harm to the developing fetus. T stands for Toxoplasmosis, O for Other infections such as syphilis and varicella, R for Rubella, C for Cytomegalovirus, and H for Herpes simplex. All four of these options are components of or fall within the TORCH classification and pose significant teratogenic and neonatal risks.
Why the other options are incorrect:
B. Toxemia — Toxemia is an outdated term for preeclampsia, which is a hypertensive disorder of pregnancy. It is not an infectious condition and has no place in the TORCH acronym. It is unrelated to the group of congenital infections the TORCH framework addresses.
2. A 24-year-old female, G2P1, at 35 weeks and 2 days gestation, arrives at the labor and delivery triage unit. She reports a sudden gush of clear fluid from her vagina two hours ago. She states she is not experiencing any painful or regular contractions. Vital signs: Temp 98.4°F, HR 82, RR 18, BP 118/74. Vaginal discharge shows clear watery fluid continuously pooling in the vaginal vault. FHR monitor shows baseline 145, moderate variability, positive for accelerations, no decelerations. Uterine activity shows irregular mild contractions every 6 to 10 minutes. Which action should the nurse take?
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Assist the registered nurse with a sterile speculum exam to confirm spontaneous rupture of membranes (SROM).
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Instruct the patient to ambulate around the unit to encourage regular contractions.
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Administer an immediate bolus of IV oxytocin to progress the labor.
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Prepare the patient for an immediate emergency cesarean delivery.
Explanation
Explanation
Correct Answer: (A) Assist the registered nurse with a sterile speculum exam to confirm spontaneous rupture of membranes (SROM).
The clinical presentation of a sudden gush of clear fluid followed by continuous pooling of watery fluid in the vaginal vault is highly suggestive of spontaneous rupture of membranes. Before any management decisions are made, the diagnosis must be confirmed through a sterile speculum examination, which allows visualization of fluid pooling at the cervix, ferning on a microscope slide, and nitrazine paper testing to confirm amniotic fluid. At 35 weeks and 2 days gestation, this is a preterm prelabor rupture of membranes situation requiring careful assessment and a provider-guided management plan. The fetal heart rate tracing is currently reassuring with moderate variability and accelerations, making emergency cesarean delivery unwarranted at this time.
Why the other options are incorrect:
B. Instruct the patient to ambulate around the unit to encourage regular contractions — Ambulation to stimulate labor is inappropriate in a preterm gestation without a confirmed rupture of membranes and without a clear clinical plan established by the provider. Stimulating labor at 35 weeks without full assessment could cause harm.
C. Administer an immediate bolus of IV oxytocin to progress the labor — Oxytocin administration is a provider-ordered intervention that requires confirmed rupture of membranes, cervical assessment, and a clinical decision regarding management of preterm SROM. The nurse cannot independently initiate this without confirmation and an order.
D. Prepare the patient for an immediate emergency cesarean delivery — The fetal heart rate tracing is reassuring with no decelerations, and there is no indication of fetal compromise or placental emergency. An emergency cesarean delivery is not indicated based on the current clinical data.
Correct Answer: (A) Assist the registered nurse with a sterile speculum exam to confirm spontaneous rupture of membranes (SROM).
The clinical presentation of a sudden gush of clear fluid followed by continuous pooling of watery fluid in the vaginal vault is highly suggestive of spontaneous rupture of membranes. Before any management decisions are made, the diagnosis must be confirmed through a sterile speculum examination, which allows visualization of fluid pooling at the cervix, ferning on a microscope slide, and nitrazine paper testing to confirm amniotic fluid. At 35 weeks and 2 days gestation, this is a preterm prelabor rupture of membranes situation requiring careful assessment and a provider-guided management plan. The fetal heart rate tracing is currently reassuring with moderate variability and accelerations, making emergency cesarean delivery unwarranted at this time.
Why the other options are incorrect:
B. Instruct the patient to ambulate around the unit to encourage regular contractions — Ambulation to stimulate labor is inappropriate in a preterm gestation without a confirmed rupture of membranes and without a clear clinical plan established by the provider. Stimulating labor at 35 weeks without full assessment could cause harm.
C. Administer an immediate bolus of IV oxytocin to progress the labor — Oxytocin administration is a provider-ordered intervention that requires confirmed rupture of membranes, cervical assessment, and a clinical decision regarding management of preterm SROM. The nurse cannot independently initiate this without confirmation and an order.
D. Prepare the patient for an immediate emergency cesarean delivery — The fetal heart rate tracing is reassuring with no decelerations, and there is no indication of fetal compromise or placental emergency. An emergency cesarean delivery is not indicated based on the current clinical data.
3. The nurse would notify the newborn intensive care team to be present at the time of birth for an infant born to which of the following laboring patients?
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38-year-old with history of hypertension.
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27-year-old with history of anxiety.
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34-year-old with history of kidney stones.
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30-year-old with history of depression.
Explanation
Explanation
Correct Answer: (A) 38-year-old with history of hypertension.
Maternal hypertension, particularly chronic hypertension and conditions such as preeclampsia, significantly increases the risk of neonatal complications at delivery. Infants born to hypertensive mothers are at increased risk for placental insufficiency, intrauterine growth restriction, preterm birth, perinatal asphyxia, and need for resuscitation at birth. The neonatal intensive care team should be present to provide immediate assessment and intervention if needed. Advanced maternal age combined with hypertension further elevates the risk profile of this delivery.
Why the other options are incorrect:
B. 27-year-old with history of anxiety — Maternal anxiety is a mental health condition managed with therapy and potentially medication. While some psychiatric medications can have neonatal effects, anxiety as a diagnosis alone does not routinely require NICU team presence at delivery without additional specific clinical risk factors.
C. 34-year-old with history of kidney stones — Nephrolithiasis is a maternal urological condition that does not directly threaten fetal oxygenation or neonatal transition. There is no established link between kidney stones and the need for neonatal resuscitation team presence at delivery.
D. 30-year-old with history of depression — Maternal depression is a psychiatric condition that, while important to address in the postpartum period, does not create direct neonatal physiological risks at the time of birth that would necessitate NICU team presence at delivery in the absence of other complicating factors.
Correct Answer: (A) 38-year-old with history of hypertension.
Maternal hypertension, particularly chronic hypertension and conditions such as preeclampsia, significantly increases the risk of neonatal complications at delivery. Infants born to hypertensive mothers are at increased risk for placental insufficiency, intrauterine growth restriction, preterm birth, perinatal asphyxia, and need for resuscitation at birth. The neonatal intensive care team should be present to provide immediate assessment and intervention if needed. Advanced maternal age combined with hypertension further elevates the risk profile of this delivery.
Why the other options are incorrect:
B. 27-year-old with history of anxiety — Maternal anxiety is a mental health condition managed with therapy and potentially medication. While some psychiatric medications can have neonatal effects, anxiety as a diagnosis alone does not routinely require NICU team presence at delivery without additional specific clinical risk factors.
C. 34-year-old with history of kidney stones — Nephrolithiasis is a maternal urological condition that does not directly threaten fetal oxygenation or neonatal transition. There is no established link between kidney stones and the need for neonatal resuscitation team presence at delivery.
D. 30-year-old with history of depression — Maternal depression is a psychiatric condition that, while important to address in the postpartum period, does not create direct neonatal physiological risks at the time of birth that would necessitate NICU team presence at delivery in the absence of other complicating factors.
4. The nurse caring for a preterm infant observes the skin has a yellow color and the infant's bilirubin level is rising. What is the nurse's primary goal?
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Monitoring bilirubin levels
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Assessing for skin breakdown
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Protecting the infant's eyes
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Preventing brain damage
Explanation
Explanation
Correct Answer: (D) Preventing brain damage.
The yellow skin color and rising bilirubin level indicate neonatal jaundice, specifically hyperbilirubinemia. The primary and overarching goal of all interventions in hyperbilirubinemia management is to prevent the bilirubin level from rising to neurotoxic levels. When unconjugated bilirubin crosses the blood-brain barrier and deposits in brain tissue, it causes a devastating and irreversible condition called kernicterus, which leads to permanent neurological damage, cerebral palsy, hearing loss, and intellectual disability. All other nursing actions, including monitoring levels, phototherapy, and eye protection, serve this single most important goal.
Why the other options are incorrect:
A. Monitoring bilirubin levels — Bilirubin monitoring is an essential nursing action but is a means to an end rather than the primary goal itself. Monitoring enables timely intervention but does not directly prevent harm on its own.
B. Assessing for skin breakdown — Skin assessment is relevant during phototherapy because prolonged exposure can cause skin irritation and rash, but it is a secondary safety concern, not the primary goal driving care in hyperbilirubinemia management.
C. Protecting the infant's eyes — Eye shields are applied during phototherapy to protect the retinas from high-intensity light exposure. This is an important safety measure but again represents a supportive intervention rather than the overarching primary goal of preventing neurological injury.
Correct Answer: (D) Preventing brain damage.
The yellow skin color and rising bilirubin level indicate neonatal jaundice, specifically hyperbilirubinemia. The primary and overarching goal of all interventions in hyperbilirubinemia management is to prevent the bilirubin level from rising to neurotoxic levels. When unconjugated bilirubin crosses the blood-brain barrier and deposits in brain tissue, it causes a devastating and irreversible condition called kernicterus, which leads to permanent neurological damage, cerebral palsy, hearing loss, and intellectual disability. All other nursing actions, including monitoring levels, phototherapy, and eye protection, serve this single most important goal.
Why the other options are incorrect:
A. Monitoring bilirubin levels — Bilirubin monitoring is an essential nursing action but is a means to an end rather than the primary goal itself. Monitoring enables timely intervention but does not directly prevent harm on its own.
B. Assessing for skin breakdown — Skin assessment is relevant during phototherapy because prolonged exposure can cause skin irritation and rash, but it is a secondary safety concern, not the primary goal driving care in hyperbilirubinemia management.
C. Protecting the infant's eyes — Eye shields are applied during phototherapy to protect the retinas from high-intensity light exposure. This is an important safety measure but again represents a supportive intervention rather than the overarching primary goal of preventing neurological injury.
5. A nurse is caring for a patient attempting a trial of labor after cesarean (TOLAC). The patient suddenly reports sharp pain between her shoulder blades and chest pain with inspiration. The nurse notes fetal bradycardia on the monitor and an abrupt cessation of uterine contractions. Which nursing actions should the nurse take? (Select all that apply.)
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Continue to monitor the client because these findings are expected during transition labor.
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Reposition the client to supine to improve fetal perfusion.
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Administer high flow oxygen via nonrebreather mask.
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Notify the rapid response team and healthcare provider immediately.
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Prepare the client for an emergency cesarean birth.
Explanation
Explanation
Correct Answers: (C) Administer high flow oxygen via nonrebreather mask, (D) Notify the rapid response team and healthcare provider immediately, and (E) Prepare the client for an emergency cesarean birth.
The clinical presentation described is a classic and life-threatening picture of uterine rupture, which is one of the most feared complications of TOLAC. The triad of sudden sharp pain radiating to the shoulder blades, abrupt cessation of uterine contractions, and fetal bradycardia strongly indicates that the uterine wall has torn, causing the fetus and amniotic fluid to potentially enter the abdominal cavity and disrupting placental perfusion. Administering high-flow oxygen via nonrebreather mask is immediately indicated to maximize oxygen delivery to both the mother and the fetus in the setting of acute hemodynamic compromise. Notifying the rapid response team and healthcare provider immediately is critical because uterine rupture is a surgical emergency requiring the fastest possible response from the full care team. Preparing the client for an emergency cesarean birth is the definitive intervention, as the fetus must be delivered immediately and the uterine rupture must be surgically repaired to prevent maternal exsanguination and fetal death.
Why the other options are incorrect:
A. Continue to monitor the client because these findings are expected during transition labor — This response is dangerous and incorrect. Sudden sharp interscapular pain, cessation of contractions, and fetal bradycardia are never normal findings during any stage of labor. These are emergency warning signs of uterine rupture requiring immediate action, not observation.
B. Reposition the client to supine to improve fetal perfusion — Repositioning to supine is a standard intervention for fetal heart rate decelerations caused by umbilical cord compression or supine hypotensive syndrome. However, in suspected uterine rupture, repositioning alone is grossly insufficient and delays the emergent interventions required. Furthermore, supine positioning in a patient with suspected internal hemorrhage may worsen hemodynamic instability by compressing the inferior vena cava and reducing venous return.
Correct Answers: (C) Administer high flow oxygen via nonrebreather mask, (D) Notify the rapid response team and healthcare provider immediately, and (E) Prepare the client for an emergency cesarean birth.
The clinical presentation described is a classic and life-threatening picture of uterine rupture, which is one of the most feared complications of TOLAC. The triad of sudden sharp pain radiating to the shoulder blades, abrupt cessation of uterine contractions, and fetal bradycardia strongly indicates that the uterine wall has torn, causing the fetus and amniotic fluid to potentially enter the abdominal cavity and disrupting placental perfusion. Administering high-flow oxygen via nonrebreather mask is immediately indicated to maximize oxygen delivery to both the mother and the fetus in the setting of acute hemodynamic compromise. Notifying the rapid response team and healthcare provider immediately is critical because uterine rupture is a surgical emergency requiring the fastest possible response from the full care team. Preparing the client for an emergency cesarean birth is the definitive intervention, as the fetus must be delivered immediately and the uterine rupture must be surgically repaired to prevent maternal exsanguination and fetal death.
Why the other options are incorrect:
A. Continue to monitor the client because these findings are expected during transition labor — This response is dangerous and incorrect. Sudden sharp interscapular pain, cessation of contractions, and fetal bradycardia are never normal findings during any stage of labor. These are emergency warning signs of uterine rupture requiring immediate action, not observation.
B. Reposition the client to supine to improve fetal perfusion — Repositioning to supine is a standard intervention for fetal heart rate decelerations caused by umbilical cord compression or supine hypotensive syndrome. However, in suspected uterine rupture, repositioning alone is grossly insufficient and delays the emergent interventions required. Furthermore, supine positioning in a patient with suspected internal hemorrhage may worsen hemodynamic instability by compressing the inferior vena cava and reducing venous return.
6. A nurse is caring for a patient attempting a trial of labor after cesarean (TOLAC). The patient suddenly reports sharp pain between her shoulder blades and chest pain with inspiration. The nurse notes fetal bradycardia on the monitor and an abrupt cessation of uterine contractions. The nurse recognizes that the patient may be experiencing:
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Pulmonary embolism
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Cervical laceration
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Uterine Rupture
-
Orthostatic hypotension
Explanation
Explanation
Correct Answer: (C) Uterine Rupture.
Uterine rupture is a catastrophic obstetric emergency that occurs when the uterine wall tears, most commonly along a previous uterine scar such as a prior cesarean incision. In TOLAC patients, the scar tissue is at risk for giving way under the pressures of active labor. The classic triad of sudden sharp pain radiating to the shoulder blades or chest, abrupt cessation of previously present uterine contractions as the uterus loses its structural integrity, and fetal bradycardia due to sudden placental compromise and fetal hypoxia is the hallmark presentation of uterine rupture and requires immediate surgical intervention.
Why the other options are incorrect:
A. Pulmonary embolism — A pulmonary embolism presents with sudden onset chest pain, dyspnea, tachycardia, and hypoxia. While chest pain is present in this scenario, the simultaneous cessation of uterine contractions and fetal bradycardia are not features of pulmonary embolism and point specifically toward a uterine catastrophe rather than a thromboembolic event.
B. Cervical laceration — Cervical lacerations typically occur after delivery and present with bright red vaginal bleeding despite a well-contracted uterus. They do not cause interscapular pain, cessation of contractions, or fetal bradycardia during active labor.
D. Orthostatic hypotension — Orthostatic hypotension is caused by positional changes reducing venous return and presents with dizziness and lightheadedness. It does not cause sharp interscapular pain, cessation of labor contractions, or acute fetal heart rate changes.
Correct Answer: (C) Uterine Rupture.
Uterine rupture is a catastrophic obstetric emergency that occurs when the uterine wall tears, most commonly along a previous uterine scar such as a prior cesarean incision. In TOLAC patients, the scar tissue is at risk for giving way under the pressures of active labor. The classic triad of sudden sharp pain radiating to the shoulder blades or chest, abrupt cessation of previously present uterine contractions as the uterus loses its structural integrity, and fetal bradycardia due to sudden placental compromise and fetal hypoxia is the hallmark presentation of uterine rupture and requires immediate surgical intervention.
Why the other options are incorrect:
A. Pulmonary embolism — A pulmonary embolism presents with sudden onset chest pain, dyspnea, tachycardia, and hypoxia. While chest pain is present in this scenario, the simultaneous cessation of uterine contractions and fetal bradycardia are not features of pulmonary embolism and point specifically toward a uterine catastrophe rather than a thromboembolic event.
B. Cervical laceration — Cervical lacerations typically occur after delivery and present with bright red vaginal bleeding despite a well-contracted uterus. They do not cause interscapular pain, cessation of contractions, or fetal bradycardia during active labor.
D. Orthostatic hypotension — Orthostatic hypotension is caused by positional changes reducing venous return and presents with dizziness and lightheadedness. It does not cause sharp interscapular pain, cessation of labor contractions, or acute fetal heart rate changes.
7. The nurse is providing education to parents of an infant with cleft palate. What will the nurse instruct the parents to report immediately?
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Ear infections
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Facial paralysis
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Drooling
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Increased intracranial pressure
Explanation
Explanation
Correct Answer: (A) Ear infections.
Infants with cleft palate have abnormal anatomy of the palate and pharyngeal muscles, which affects the function of the Eustachian tubes. This dysfunction leads to poor middle ear drainage and a significantly increased risk of recurrent otitis media, or ear infections. If left untreated, repeated ear infections can result in hearing loss, which in turn impairs speech and language development. Parents must be instructed to report signs of ear infection immediately so treatment can be initiated promptly.
Why Other Options are Incorrect:
B. Facial paralysis — Facial paralysis is not a recognized complication directly associated with cleft palate and is not a priority finding for parents to monitor at home.
C. Drooling — Drooling is expected and normal in infants regardless of cleft palate. It does not represent an urgent or reportable finding requiring immediate notification.
D. Increased intracranial pressure — While serious, increased intracranial pressure is not a complication specifically associated with cleft palate. It is not a condition parents would be educated to monitor for in this context.
Correct Answer: (A) Ear infections.
Infants with cleft palate have abnormal anatomy of the palate and pharyngeal muscles, which affects the function of the Eustachian tubes. This dysfunction leads to poor middle ear drainage and a significantly increased risk of recurrent otitis media, or ear infections. If left untreated, repeated ear infections can result in hearing loss, which in turn impairs speech and language development. Parents must be instructed to report signs of ear infection immediately so treatment can be initiated promptly.
Why Other Options are Incorrect:
B. Facial paralysis — Facial paralysis is not a recognized complication directly associated with cleft palate and is not a priority finding for parents to monitor at home.
C. Drooling — Drooling is expected and normal in infants regardless of cleft palate. It does not represent an urgent or reportable finding requiring immediate notification.
D. Increased intracranial pressure — While serious, increased intracranial pressure is not a complication specifically associated with cleft palate. It is not a condition parents would be educated to monitor for in this context.
8. A 24-year-old female, G2P1, at 35 weeks and 2 days gestation, arrives at the labor and delivery triage unit. She reports a sudden gush of clear fluid from her vagina two hours ago. She states she is not experiencing any painful or regular contractions. Vital signs: Temp 98.4°F, HR 82, RR 18, BP 118/74. Vaginal discharge shows clear watery fluid continuously pooling in the vaginal vault. FHR monitor shows baseline 145, moderate variability, positive for accelerations, no decelerations. Uterine activity shows irregular mild contractions every 6 to 10 minutes.
Which maternal-fetal complication is the patient most likely experiencing?
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Abruptio Placentae
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Supine Hypotensive Syndrome
-
Endometritis
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Chorioamnionitis
Explanation
Explanation
Correct Answer: (D) Chorioamnionitis.
Chorioamnionitis is an infection and inflammation of the fetal membranes and amniotic fluid, most commonly occurring following prolonged or premature rupture of membranes. This patient's presentation of a sudden gush of clear fluid with continuous pooling in the vaginal vault is consistent with rupture of membranes. Once the protective barrier of intact membranes is lost, ascending bacteria from the vaginal flora can infect the amniotic cavity. The combination of preterm gestation, ruptured membranes, and the clinical setting makes chorioamnionitis the most likely complication this patient is at risk for and most likely experiencing.
Why the other options are incorrect:
A. Abruptio Placentae — Placental abruption presents with sudden onset of painful uterine contractions, uterine rigidity, and dark vaginal bleeding caused by premature separation of the placenta from the uterine wall. This patient denies pain and contractions, and the fluid is clear and watery, not bloody, making abruption inconsistent with this clinical picture.
B. Supine Hypotensive Syndrome — This condition occurs when the gravid uterus compresses the inferior vena cava when the mother lies flat on her back, causing a sudden drop in blood pressure and dizziness. The patient's blood pressure is 118/74 and she is ambulatory and presenting to triage, making this diagnosis not applicable to her current situation.
C. Endometritis — Endometritis is an infection of the uterine lining that typically develops postpartum, most commonly after cesarean delivery. This patient is antepartum and has not yet delivered, making endometritis an inappropriate diagnosis at this stage of care.
Correct Answer: (D) Chorioamnionitis.
Chorioamnionitis is an infection and inflammation of the fetal membranes and amniotic fluid, most commonly occurring following prolonged or premature rupture of membranes. This patient's presentation of a sudden gush of clear fluid with continuous pooling in the vaginal vault is consistent with rupture of membranes. Once the protective barrier of intact membranes is lost, ascending bacteria from the vaginal flora can infect the amniotic cavity. The combination of preterm gestation, ruptured membranes, and the clinical setting makes chorioamnionitis the most likely complication this patient is at risk for and most likely experiencing.
Why the other options are incorrect:
A. Abruptio Placentae — Placental abruption presents with sudden onset of painful uterine contractions, uterine rigidity, and dark vaginal bleeding caused by premature separation of the placenta from the uterine wall. This patient denies pain and contractions, and the fluid is clear and watery, not bloody, making abruption inconsistent with this clinical picture.
B. Supine Hypotensive Syndrome — This condition occurs when the gravid uterus compresses the inferior vena cava when the mother lies flat on her back, causing a sudden drop in blood pressure and dizziness. The patient's blood pressure is 118/74 and she is ambulatory and presenting to triage, making this diagnosis not applicable to her current situation.
C. Endometritis — Endometritis is an infection of the uterine lining that typically develops postpartum, most commonly after cesarean delivery. This patient is antepartum and has not yet delivered, making endometritis an inappropriate diagnosis at this stage of care.
9. A nurse is caring for a pregnant client hospitalized with severe preeclampsia. During assessment, the client suddenly develops generalized seizure activity. Which action should the nurse take first?
-
Prepare for the administration of IV magnesium sulfate.
-
Administer oxygen by facemask.
-
Check the blood pressure and fetal heart tones.
-
Clear and maintain an open airway.
Explanation
Explanation
Correct Answer: (D) Clear and maintain an open airway.
When a client develops a seizure, the immediate priority follows the ABCs of emergency care: Airway, Breathing, and Circulation. During a generalized seizure, the client loses voluntary muscle control, which can compromise the airway through jaw clenching, tongue displacement, or aspiration of secretions. Clearing and maintaining a patent airway is the first and most critical action because without a secure airway, all subsequent interventions including oxygen delivery and medication administration cannot be effective.
Why the other options are incorrect:
A. Prepare for the administration of IV magnesium sulfate — Magnesium sulfate is the drug of choice for treating and preventing further eclamptic seizures and will be administered after the immediate seizure is managed. However, airway security must be established first before any medication preparation.
B. Administer oxygen by facemask — Supplemental oxygen is essential during and after a seizure to address maternal and fetal hypoxia, but it is the second priority after securing the airway. Oxygen cannot be effectively delivered to an obstructed or compromised airway.
C. Check the blood pressure and fetal heart tones — Monitoring maternal blood pressure and fetal status is critically important in severe preeclampsia and eclampsia but represents assessment rather than an immediate life-saving intervention. Airway management takes absolute precedence over assessment during an active seizure.
Correct Answer: (D) Clear and maintain an open airway.
When a client develops a seizure, the immediate priority follows the ABCs of emergency care: Airway, Breathing, and Circulation. During a generalized seizure, the client loses voluntary muscle control, which can compromise the airway through jaw clenching, tongue displacement, or aspiration of secretions. Clearing and maintaining a patent airway is the first and most critical action because without a secure airway, all subsequent interventions including oxygen delivery and medication administration cannot be effective.
Why the other options are incorrect:
A. Prepare for the administration of IV magnesium sulfate — Magnesium sulfate is the drug of choice for treating and preventing further eclamptic seizures and will be administered after the immediate seizure is managed. However, airway security must be established first before any medication preparation.
B. Administer oxygen by facemask — Supplemental oxygen is essential during and after a seizure to address maternal and fetal hypoxia, but it is the second priority after securing the airway. Oxygen cannot be effectively delivered to an obstructed or compromised airway.
C. Check the blood pressure and fetal heart tones — Monitoring maternal blood pressure and fetal status is critically important in severe preeclampsia and eclampsia but represents assessment rather than an immediate life-saving intervention. Airway management takes absolute precedence over assessment during an active seizure.
10. The nurse bathing a newborn and performing a routine musculoskeletal assessment recognizes a sign of developmental hip dysplasia. Which sign(s) will the nurse document in the infant's medical record? (Select all that apply.)
-
Positive Ortolani or Barlow maneuver
-
Plantar grasp reflex present bilaterally
-
Hypotonicity of the leg muscles
-
Two skin folds on the back of each thigh
-
One leg is shorter than the other
Explanation
Explanation
Correct Answers: (A) Positive Ortolani or Barlow maneuver, (C) Hypotonicity of the leg muscles, and (E) One leg is shorter than the other.
Developmental dysplasia of the hip (DDH) is characterized by an abnormal relationship between the femoral head and the acetabulum. A positive Ortolani maneuver produces a palpable clunk as the dislocated femoral head reduces back into the acetabulum during abduction, while a positive Barlow maneuver demonstrates the hip dislocating out of the socket during adduction. These are the gold standard physical examination findings for DDH. Hypotonicity of the leg muscles is associated with DDH as the abnormal hip positioning affects muscle development and tone around the joint. Leg length discrepancy, where one leg appears shorter than the other, is also a classic finding of DDH caused by the proximal displacement of the femoral head on the affected side.
Why the other options are incorrect:
B. Plantar grasp reflex present bilaterally — The plantar grasp reflex is a normal primitive reflex in newborns that disappears around 9 to 12 months of age. Its bilateral presence is a normal finding and is not associated with developmental hip dysplasia.
D. Two skin folds on the back of each thigh — Symmetric skin folds on the back of both thighs are a normal finding in newborns. The significant finding in DDH is asymmetric thigh skin folds, where the number and position of folds differ between the two legs, indicating unequal leg positioning caused by hip dislocation.
Correct Answers: (A) Positive Ortolani or Barlow maneuver, (C) Hypotonicity of the leg muscles, and (E) One leg is shorter than the other.
Developmental dysplasia of the hip (DDH) is characterized by an abnormal relationship between the femoral head and the acetabulum. A positive Ortolani maneuver produces a palpable clunk as the dislocated femoral head reduces back into the acetabulum during abduction, while a positive Barlow maneuver demonstrates the hip dislocating out of the socket during adduction. These are the gold standard physical examination findings for DDH. Hypotonicity of the leg muscles is associated with DDH as the abnormal hip positioning affects muscle development and tone around the joint. Leg length discrepancy, where one leg appears shorter than the other, is also a classic finding of DDH caused by the proximal displacement of the femoral head on the affected side.
Why the other options are incorrect:
B. Plantar grasp reflex present bilaterally — The plantar grasp reflex is a normal primitive reflex in newborns that disappears around 9 to 12 months of age. Its bilateral presence is a normal finding and is not associated with developmental hip dysplasia.
D. Two skin folds on the back of each thigh — Symmetric skin folds on the back of both thighs are a normal finding in newborns. The significant finding in DDH is asymmetric thigh skin folds, where the number and position of folds differ between the two legs, indicating unequal leg positioning caused by hip dislocation.
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