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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The pattern of contractions is important in assessing labor, but the presence of regular contractions alone does not confirm true labor. It is the changes in the cervix that indicate progress in labor.
B. The station of the presenting part (the level at which the baby's head has descended into the pelvis) is also a factor in labor, but it is not the primary indicator of true labor. Changes in the cervix are more indicative.
C. Changes in the cervix are a key sign of true labor.
True labor involves cervical effacement (thinning) and dilation (opening). These changes in the cervix signify progress in the labor process.
D. Rupture of the membranes (water breaking) can be a sign of labor, but it doesn't confirm true labor on its own. It might occur before, during, or after labor has begun.
Correct Answer is D
Explanation
A. Contractions lasting longer than 90 seconds: Prolonged contractions lasting longer than 90 seconds may indicate uterine hyperstimulation, which can compromise fetal oxygenation and lead to fetal distress. This finding should be reported to the provider promptly for further evaluation and management.
B. Client reports feeling contractions in the lower back: This is a common sensation during labor and may not necessarily indicate a complication. However, if associated with other signs of fetal distress, it should be reported.
C. Contractions occurring every 3 to 5 minutes: This frequency is within the normal range for the active phase of labor and does not necessarily indicate a problem. However, it is essential to consider the duration and intensity of contractions along with this frequency.
D. Contractions are strong in intensity: While strong contractions are typical during the active phase of labor, the intensity alone may not be a cause for concern unless they are associated with uterine hyperstimulation.
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