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 D
Explanation
Rationale for A: While contacting a shelter in another county might be a good long-term option, the client should prioritize preparing for an immediate, safe escape rather than focusing on geographic distance.
Rationale for B: Telling the client to leave immediately may not be feasible or safe. The client needs to be prepared with a well-thought-out plan, including knowing when and how to leave, based on the safest opportunity.
Rationale for C: Keeping a packed bag by the front door may alert the abuser and increase the risk of violence. Instead, the bag should be kept in a secure and hidden location to avoid raising suspicion.
Rationale for D: Rehearsing an escape route is a critical component of a safety plan. It ensures the client knows how to leave quickly and safely in case of an emergency, which is vital for their safety.
Correct Answer is A
Explanation
A. Correct. Ampicillin is a penicillin antibiotic and is contraindicated in clients who are allergic to penicillin.
B. Incorrect. Erythromycin is not a penicillin antibiotic and can be an alternative for clients allergic to penicillin.
C. Incorrect. Cefazolin is a cephalosporin antibiotic and is not related to penicillin. It can be used as an alternative in clients allergic to penicillin.
D. Incorrect. Clindamycin is not related to penicillin and can be used as an alternative in clients allergic to penicillin.
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