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

Answer and Explanation

The Correct Answer is C

c. Weak cry

Explanation: In the context of a newborn with shoulder dystocia, a weak cry can be an indication of pain. Newborns communicate their discomfort or pain through crying, and a weak cry may suggest that the newborn is experiencing pain or distress.

Option a, lip-smacking, is not necessarily a specific indication of pain in this situation. Lip-smacking can

occur due to various reasons and may not solely indicate pain.

Option b, a stiﬀ posture, may be more indicative of muscle tension or rigidity rather than pain in this

scenario.

Option d, tongue-darting, is not a specific indicator of pain in this context. Tongue-darting is a common behavior in newborns and may not be directly related to pain.

By recognizing a weak cry as a potential indication of pain in the newborn with shoulder dystocia, the nurse

can provide appropriate interventions and support to manage the newborn's pain and discomfort.

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Correct Answer is D

Explanation

d. Pinpoint pupils.

Explanation:

Opioid intoxication is characterized by various signs and symptoms, including central nervous system depression. One common manifestation of opioid intoxication is pinpoint pupils (miosis), which is caused by the eﬀect of opioids on the pupillary constrictor muscles. The pupils become constricted and appear as small dots, hence the term "pinpoint."

The other options are not typical manifestations of opioid intoxication. Tachycardia (rapid heart rate) is more commonly associated with stimulant use rather than opioids. Mental alertness is typically reduced in cases of opioid intoxication, as opioids cause sedation and CNS depression. Hyperreﬂexia (exaggerated reﬂexes) is not a typical finding in opioid intoxication; instead, it may occur in withdrawal from certain substances such as alcohol or benzodiazepines.

A. "You can resume a regular diet 3 days after your procedure." B. "You can take a shower 1 day after your procedure." C. "You can begin exercising 2 days after your procedure." D. "You can return to school 1 week after your procedure."

Correct Answer is B

Explanation

The instruction that the nurse should include is "You can take a shower 1 day after your procedure." According to the Cleveland Clinic, the morning after the procedure, the client may take the dressing oﬀ the catheter insertion site. The easiest way to do this is when showering, get the tape and dressing wet and remove it.

Option a is incorrect because there is no information suggesting that a client must wait 3 days before resuming a regular diet after a cardiac catheterization.

Option c is incorrect because according to the Cleveland Clinic, clients should gradually increase their activities until they reach their normal activity level within one week after the procedure.

Option d is incorrect because there is no information suggesting that a client must wait 1 week before returning to school after cardiac catheterization.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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