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","B","C","D","E"]
Explanation
A. In small-for-gestational age infants, kangaroo care may increase heat loss due to evaporation, conduction, or convection from the parent's skin or clothing. The nurse should minimize kangaroo care and use other methods of warming such as radiant warmers, incubators, or swaddling.
B. Assessing the axillary temperature regularly helps monitor the infant's temperature and response to interventions.
C. Encouraging skin-to-skin contact helps promote thermal regulation and bonding between the infant and parents. Unlike kangaroo care, skin-to-skin contact does not involve covering the infant with clothing or blankets, which can reduce heat loss by radiation or convection. The nurse should encourage skin-to-skin contact when possible and monitor the infant's temperature closely.
D. Assessing the environment for sources of heat loss is important for minimizing heat loss and promoting thermal regulation.
E. Reviewing maternal history can provide insights into potential risk factors or contributing factors to the infant's condition, such as maternal age, parity, weight, height, nutrition, smoking, alcohol, drug use, chronic diseases, infections, placental abnormalities, fetal anomalies, or complications during pregnancy or delivery.
F. Bathing the neonate with warmer water may increase the risk of overheating and should be avoided in infants at risk of thermal instability.
Correct Answer is ["A","B","D","E"]
Explanation
A. Toddlers require adequate calcium intake for proper bone development, with an average intake of around 700 mg per day.
B. Adequate calcium intake, along with appropriate exercise, helps in proper bone mineralization, ensuring healthy bone development.
C. Restricting fat intake is not recommended for children younger than 2 years, as they need fats for brain development and overall growth.
D. Extending breastfeeding into toddlerhood provides numerous health benefits, including optimal nutrition, immune support, and emotional bonding.
E. Weaning from the bottle should occur by 6 to 12 months of age to prevent dental caries, ear infections, and overfeeding.
F. Toddlers tend to have low iron intake due to their preference for milk and other non-iron-rich foods, which can lead to iron deficiency anemia.
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