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 D
Explanation
A. Brownish vaginal discharge may indicate the presence of old blood or mucus and is not necessarily a cause for concern in the absence of other signs or symptoms.
B. Contractions occurring every 4 to 5 minutes are within the normal frequency range during the first stage of labor.
C. Pink mucoid vaginal discharge, also known as the "bloody show," is a common occurrence in early labor and is not typically a cause for immediate concern.
D. Contractions lasting 100 seconds are excessively long and are a cause for concern.
Prolonged contractions can lead to decreased uterine blood flow, impacting fetal oxygenation. Such prolonged contractions should be assessed and addressed promptly.
Correct Answer is D
Explanation
The correct answer is D. Variable decelerations.
A. Accelerations in the fetal heart rate are generally considered reassuring. Accelerations are an indication of fetal well-being and are often seen in response to fetal movement.
B. Early decelerations are typically associated with head compression during contractions and are considered a normal response to the pressure on the fetal head.
C. Late decelerations are indicative of uteroplacental insufficiency.
Late decelerations occur after the peak of the contraction and are associated with inadequate oxygenation to the fetus. This pattern raises concerns about the baby's well-being.
D. Variable decelerations are associated with umbilical cord compression.
Variable decelerations are abrupt decreases in the fetal heart rate that vary in duration, depth, and timing. They often coincide with contractions and suggest compression or occlusion of the umbilical cord.
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