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 B
Explanation
- G: 4 pregnancies (2017 spontaneous abortion, 2018 twins with one demise, 2020 NSVD, and the current pregnancy)
- T: 2 term births (2020 and 2022)
- P: 1 preterm birth
- A: 1 abortion/miscarriage (2017 spontaneous abortion)
- L: 4 living children (twins from 2018 and the child born in 2020)
Correct Answer is B
Explanation
A. Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
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