A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?
Sunken fontanels
Retinal hemorrhage
Laceration to forearm.
Large bruises on the body
The Correct Answer is B
A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Offer the newborn a pacifier. This can help soothe the newborn and provide comfort, as infants exposed to opioids in utero often exhibit increased need for sucking.
B. Observe the newborn in a well-lit nursery. This is not appropriate as bright lights can overstimulate and distress the newborn.
C. Maintain a low stimulation environment. This helps reduce stress and irritability in newborns undergoing withdrawal, who can be hypersensitive to stimuli.
D. Administer oral glucose for comfort. Glucose is not typically used for comfort in NAS management; comforting measures like swaddling and pacifiers are preferred.
E. Swaddle the newborn tightly. Tight swaddling can provide a sense of security and help manage symptoms of neonatal abstinence syndrome (NAS) by reducing irritability and promoting sleep.
F. Feed the infant half-strength formula. Infants with NAS usually require regular, full-strength formula to meet nutritional needs unless otherwise indicated by specific feeding issues.
Correct Answer is A
Explanation
A. slight yellow vaginal discharge: Gonorrhea often presents with a purulent or yellowish vaginal discharge in females. It is one of the common symptoms along with pelvic pain and dysuria.
B. Decrease in urinary frequency: Gonorrhea can actually increase urinary frequency or cause dysuria. A decrease in frequency is not typical for gonorrhea.
C. frothy, white vaginal discharge: This is more characteristic of Trichomoniasis, not gonorrhea. Gonorrhea usually presents with a thicker, more purulent discharge.
D. low grade fever for three (3) days: While fever can be associated with many infections, it is not a common primary symptom of gonorrhea in the absence of more specific symptoms like discharge or pelvic pain.
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