A macrosomic infant in the newborn nursery is being observed for a possible fractured clavicle. For which would the nurse assess? Select all that apply.
asymmetrical movement
bruising over area
edema present
facial grimacing with movement
positive Babinski reflex
Correct Answer : A,B,C,D
A. Asymmetrical movement may indicate discomfort or restricted mobility due to a fractured clavicle.
B. Bruising over the area of the clavicle may suggest trauma and could be associated with a fracture.
C. Edema (swelling) over the fractured clavicle may be present due to inflammation and tissue injury.
D. Facial grimacing with movement could indicate pain or discomfort associated with a fractured clavicle.
E. A positive Babinski reflex is unrelated to a fractured clavicle and would not be directly assessed for this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Temperature instability, including fever or hypothermia, can be a sign of sepsis in newborns, as it reflects the body's response to infection.
B. Increased urinary output is not typically associated with sepsis in newborns and may have other causes, such as adequate fluid intake or renal function.
C. Wakefulness is a normal behavior in newborns and is not specific to sepsis.
D. Interest in feeding is a positive sign and indicates the newborn's responsiveness to hunger cues, but it is not specific to sepsis.
Correct Answer is D
Explanation
A. While acknowledging the father's concerns is important, this response doesn't provide guidance on addressing potential depression in the son.
B. Offering to refer the son for evaluation with a therapist if mood issues are noticed is important and provides proactive support and guidance for addressing potential depression but screening children with a risk factor for depression from the age of 11 is the best choice.
C. While regular screening may be indicated for at-risk teens, waiting until age 14 may miss opportunities for early intervention in some cases.
D. Screening for depression is recommended for all children aged 11 and older, especially those who have a family history of depression or other risk factors. The nurse should inform the father that screening his son for depression is important and can help identify any signs or symptoms early. This is based on the recommendations of the American Academy of Pediatrics, which state that pediatric primary care providers should screen all children and adolescents for depression at least once a year, starting from age 11.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today