A 2-month-old infant is brought to the emergency room.
Which factor should lead the RN to suspect that the child may have experienced abusive head trauma?
Sunken fontanels.
Retinal hemorrhage.
Large bruises on the body.
Laceration to the forearm.
The Correct Answer is B
Choice A rationale
Sunken fontanels are typically a sign of dehydration due to reduced intracranial pressure and are not specific to abusive head trauma. Abusive head trauma often results in elevated intracranial pressure or swelling, which would present differently. Therefore, this finding is unrelated to the mechanisms of abusive head trauma in a 2-month-old.
Choice B rationale
Retinal hemorrhages are strongly associated with abusive head trauma due to the shearing forces during shaking or impact, which rupture retinal blood vessels. This finding is a hallmark of non-accidental trauma in infants, as accidental injuries rarely cause this degree of internal ocular damage.
Choice C rationale
Large bruises on the body could indicate trauma but are not specific to abusive head trauma. Additionally, the pattern or location of bruises is significant for abuse, especially in non-mobile infants. However, bruises alone do not confirm head trauma specifically.
Choice D rationale
Lacerations, such as those on the forearm, might suggest trauma but lack specificity for abusive head trauma. Such injuries are more commonly associated with accidents or other forms of physical abuse that do not necessarily involve the head.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Restricting play activity limits physical and emotional well-being in children. While strenuous activity is discouraged during recovery, moderate activity promotes overall health and blood flow. Over-restriction is unwarranted without clinical indications. Balance in physical activity should be emphasized in sickle cell management.
Choice B rationale
Cold compresses induce vasoconstriction, which may precipitate a sickle cell crisis by reducing oxygen delivery to tissues. Warm compresses are preferred to improve blood flow and alleviate pain in these patients. Temperature management is critical in preventing vaso-occlusive complications.
Choice C rationale
Adequate hydration reduces blood viscosity, preventing sickling episodes in children with sickle cell anemia. Consistent fluid intake is a cornerstone of management, mitigating crisis frequency. Parents should encourage routine hydration to maintain hemodynamic stability in affected children.
Choice D rationale
Daily temperature monitoring is important but not sufficient standalone advice. Fever in sickle cell anemia may indicate infection or crisis, requiring prompt medical evaluation. However, comprehensive management includes hydration, pain control, and activity regulation alongside temperature monitoring. .
Correct Answer is ["6"]
Explanation
The correct answer is Apgar score of 6.
Step 1 is to evaluate each of the five components of the Apgar score at 1 minute:
- Heart rate: 120/min scores 2 points (normal heart rate is ≥100 beats per minute).
- Respiratory effort: Slow and weak cry scores 1 point (normal is a strong cry, scoring 2 points).
- Muscle tone: Some flexion of extremities scores 1 point (normal is active motion, scoring 2 points).
- Reflex irritability: Grimace in response to suctioning scores 1 point (normal is crying or withdrawal, scoring 2 points).
- Color: Body pink with blue extremities scores 1 point (normal is completely pink, scoring 2 points).
Step 2 is to sum up the points. (2 + 1 + 1 + 1 + 1) = Apgar score of 6. .
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