A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Decreased heart rate
Chin quivering
Pinpoint pupils
Slowed respirations
The Correct Answer is B
A. Decreased heart rate: This is not typically an indication of pain in a newborn. Pain can often lead to an increased heart rate as the body responds to stress or discomfort.
B. Chin quivering: This is a common sign of pain in newborns. When infants experience pain, they may exhibit facial expressions such as quivering of the chin, furrowing of the brow, or grimacing.
C. Pinpoint pupils: Pinpoint pupils are not a typical sign of pain in a newborn. This may be associated with certain medications or conditions affecting the nervous system, but it is not a direct indicator of pain.
D. Slowed respirations: While pain can sometimes cause changes in respiratory patterns, slowed respirations alone may not be a reliable indicator of pain in a newborn. Other signs, such as facial expressions or crying, are often more indicative of pain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Jitteriness.
A. Jitteriness: Jitteriness is a common manifestation of hypoglycemia in newborns. It is a tremulous movement that can be observed in response to low blood glucose levels.
B. Hypertonia: Hypertonia, or increased muscle tone, is not a typical manifestation of hypoglycemia in newborns. Instead, hypoglycemia is more likely to be associated with hypotonia or limpness.
C. Abdominal distention: Abdominal distention is not a typical sign of hypoglycemia in newborns. It may be associated with other conditions, such as gastrointestinal issues, but it is not directly related to low blood glucose levels.
D. Mottling: Mottling refers to a blotchy or uneven skin color and is not a specific sign of hypoglycemia. It can be associated with various conditions, including poor circulation, but it is not a primary indicator of low blood glucose.
Correct Answer is D
Explanation
The correct answer is D.
A. Slowing the client's rate of breathing is not directly related to the observed uniform decelerations. The primary concern is the fetal heart rate pattern.
B. Decreasing the rate of infusion of the maintenance IV solution is not the appropriate intervention for addressing the observed fetal heart rate decelerations. The focus should be on the oxytocin infusion rate.
C. Increasing the rate of infusion of the IV oxytocin is not the appropriate action.
The patient is already experiencing frequent and strong contractions, and increasing the oxytocin rate can exacerbate the decelerations and compromise fetal well-being.
D. Discontinuing the infusion of the IV oxytocin is the correct action.
The observed uniform decelerations are likely related to oxytocin-induced hyperstimulation of the uterus. Stopping or decreasing the oxytocin infusion allows for the uterine activity to decrease, potentially improving fetal heart rate patterns.
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