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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B. You can take a shower 1 day after your procedure.
Rationale:
A. You can resume a regular diet 3 days after your procedure:
There is typically no need to delay resuming a regular diet for three days after a cardiac catheterization. Most clients can resume their usual diet shortly after the procedure once they are fully awake and any nausea has resolved.
B. You can take a shower 1 day after your procedure:
It is generally safe to shower the day after a cardiac catheterization as long as the insertion site remains protected. Clients should avoid soaking in a bath or swimming until the site is fully healed to prevent infection.
C. You can begin exercising 2 days after your procedure:
Strenuous activities, including exercise, should generally be avoided for a few days to a week following a cardiac catheterization. This allows time for the insertion site to heal and reduces the risk of complications such as bleeding.
D. You can return to school 1 week after your procedure:
Most clients can return to school or normal activities within a few days, provided they feel well and avoid excessive physical exertion. A full week off is typically not necessary unless specified by the healthcare provider based on the individual’s recovery.

Correct Answer is C
Explanation
c. The bedroom extension cord is placed under a heavy nightstand.
The nurse should intervene and address the placement of the bedroom extension cord under a heavy nightstand. This poses a safety hazard as it increases the risk of electrical fire or tripping. The nurse shouldmeducate the client about the importance of using proper outlets and avoiding the use of extension cords in general, especially when they are hidden under heavy furniture.
Options a, b, and d do not require immediate intervention by the nurse:
a. The television set turned to a loud volume can be addressed by educating the client about the potential risks of prolonged exposure to loud noises and providing guidance on appropriate volume levels.
b. The presence of low chairs with no armrests in the dining room may not necessarily require immediate intervention unless there are specific safety concerns related to the client's mobility or balance. The nurse may provide general recommendations for safer seating options, especially if the client is at risk of falls or has difficulty getting up from low chairs.
d. The presence of wall-to-wall carpeting in the living room is a common feature in many homes and does not necessarily pose a safety hazard. However, the nurse may discuss general home safety measures, such as keeping the carpet clean and free of tripping hazards, especially for clients with mobility issues.
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