A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?
Lip-smacking
Stiff posture
Weak cry
Tongue-darting
The Correct Answer is C
A. Lip-smacking may indicate hunger or a desire to feed but is not necessarily indicative of pain in a newborn with shoulder dystocia.
B. Stiff posture may indicate discomfort or distress, but it is not specific to pain and can be caused by various factors.
C. A weak cry can be a sign of pain or distress in newborns. It may indicate that the newborn is experiencing discomfort related to the shoulder dystocia.
D. Tongue-darting is a normal reflex in newborns and is not typically associated with pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Prazosin is an alpha-adrenergic blocker used to treat hypertension and does not typically require a reversal agent in this situation.
B. Incorrect. While prazosin can cause orthostatic hypotension, initiation of cardiac monitoring is not typically necessary unless there are additional signs or symptoms of cardiovascular instability.
C. Correct. Prazosin can cause orthostatic hypotension, so instructing the client to stand up slowly can help prevent falls and minimize symptoms of dizziness or lightheadedness.
D. Incorrect. While prazosin can cause urinary retention, the client's blood pressure is low, suggesting hypotension rather than urinary retention as the primary concern. Therefore, instructing the client to report urinary retention is not the most appropriate action in this scenario.
Correct Answer is A
Explanation
A. Using an adhesive remover can help safely and effectively remove the adhesive residue from the skin without causing irritation or damage.
B. Scrubbing the skin around the colostomy can cause skin irritation and increase the risk of skin breakdown. Gentle cleaning with warm water and mild soap is recommended.
C. Most colostomy bags do not require suctioning of stool, as they are designed to collect fecal matter without the need for suctioning.
D. It is generally recommended to empty the colostomy bag when it is about one-third to one- half full to prevent leakage and maintain skin integrity.
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