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
The nurse should include the statement that only health care staff providing care will see the client's medical record when reinforcing teaching about confidentiality. This statement emphasizes the importance of maintaining the privacy and confidentiality of the client's personal health information.
Explanation for the other options:
a. "Your nurse will provide information about the risks and benefits of surgical procedures." While it is important for the nurse to provide information about surgical procedures, this statement does not specifically address confidentiality.
c. "The provider must grant you access to your personal health information." This statement is related to the client's rights regarding access to their personal health information. While it is important to educate clients about their rights, it is not specifically focused on confidentiality.
d. "You have to authorize our providers to prescribe treatments for your condition." This statement is related to obtaining the client's consent for treatment, which is important but not directly addressing confidentiality.
Correct Answer is A
Explanation
The nurse should allow the family as much time as they want with the client who has just died. This promotes comfort for the family and allows them to say goodbye to their loved one.
a) Using paper tape to hold the client's eyelids open is not appropriate and can be distressing for the family.
b) Placing the client in a supine position is not necessary and may not be comfortable for the client.
c) Avoiding repeating information about the client's death is not helpful. The nurse should provide clear and honest information to the family and answer any questions they may have.
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