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 B

Answer: B. Stiff posture

Rationale:
A. Lip-smacking : Lip-smacking is not typically an indication of pain in newborns. It may be associated with hunger or neurological responses, but it does not directly indicate discomfort or pain caused by shoulder dystocia or other injuries.
B. Stiff posture : A stiff posture can indicate pain in newborns, as they often exhibit hypertonicity or rigidity when experiencing discomfort. This response is a protective mechanism and may suggest the newborn is reacting to pain from potential nerve or tissue damage caused by shoulder dystocia.
C. Weak cry : While a weak cry may indicate neurological or respiratory distress, it is not a specific sign of pain. In the context of shoulder dystocia, a weak cry could reflect complications such as brachial plexus injury but does not directly signify the presence of pain.
D. Tongue-darting : Tongue-darting is more commonly associated with neurological issues or feeding difficulties rather than pain. It is not a typical behavioral response to discomfort or injury in newborns experiencing complications like shoulder dystocia.

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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.

A. Constipation B. Elevated skin patches C. Ringing in the ears D. Depression E. None F. None

Correct Answer is B

Explanation

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.

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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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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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