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ISPN考试模拟试题(258)

Question:

The physician has determined that a primigravid client in active labor requires a cesarean delivery because of cephalopelvic disproportion. After the delivery of a healthy neonate, the nurse should assess the neonate for which of the following first? 

1. Nasopharyngeal secretions. 

2. High-pitched cry. 

3. Skull fracture. 

4. Decreased muscle tone.

 


 

A neonate delivered by cesarean delivery has not had the benefit of the chest-squeezing action of a vaginal delivery, which helps remove some of the nasopharyngeal secretions. The nurse should place the neonate under the radiant warmer and suction the mouth and nares with a bulb syringe to remove nasopharyngeal secretions. 

A high-pitched cry is associated with neurologic involvement or neonatal drug withdrawal and is unrelated to cesarean delivery. Skull fractures may occur with difficult vaginal deliveries and are not typically seen with cesarean deliveries. Decreased muscle tone is associated with oversedation, neurologic impairment, or use of general anesthesia. 
CN: Health promotion and maintenance; CL: Analyze
Answer:1

翻译

问题:

内科医生已经确定,由于头盆盆骨比例失调,一个在产的初产妇需要剖腹产。健康新生儿分娩后,护士应首先评估以下哪一项?

1.鼻咽分泌物。

2.高声喊叫。

3.头骨骨折。

4.肌肉张力下降。


答案:1

剖宫产的新生儿没有阴道分娩的挤胸作用,阴道分娩有助于清除鼻咽分泌物。护士应将新生儿置于辐射加热器下,用球茎注射器抽吸口腔和鼻腔,以清除鼻咽分泌物。

高声喊叫与神经系统受累或新生儿停药有关,与剖宫产无关。颅骨骨折可能发生在难产的阴道分娩中,而在剖宫产中并不常见。肌肉张力下降与过度运动、神经损伤或全身麻醉有关。

CN:健康促进与维护;CL:分析


小编寄语:If a thing is worth doing, it is worth doing well.如果事情值得做,就值得做好。

时间:2020/5/22 11:37:33
 
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