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 C

No explanation

A. "Close your mouth around the mouthpiece." B. "Exhale immediately after inhaling." C. "Tilt your head forward while inhaling." D. "Take three quick breaths while depressing the canister."

Correct Answer is A

Explanation

The correct technique for using an albuterol MDI involves closing the mouth around the mouthpiece to create a seal. This helps ensure that the medication is delivered directly into the lungs and maximizes its effectiveness. It also helps prevent the medication from escaping and being wasted.

"Exhale immediately after inhaling": This instruction is not accurate. After closing the mouth around the mouthpiece and activating the inhaler to release the medication, the client should inhale slowly and deeply through the mouth, holding their breath for about 10 seconds if possible. Exhaling immediately after inhaling would not allow enough time for the medication to be absorbed effectively.

"Tilt your head forward while inhaling": Tilted head position is not necessary when using an albuterol MDI. The client should hold the inhaler in an upright position, with the mouthpiece directed toward their mouth. This allows for proper delivery of the medication.

"Take three quick breaths while depressing the canister": This instruction is not accurate for using an albuterol MDI. The correct technique involves taking a slow and deep breath in through the mouth, while simultaneously depressing the canister to release the medication. Taking three quick breaths may not allow enough time for adequate medication delivery.

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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

A nurse on a maternal newborn unit is assisting with the preparation of an in-service presentation about infection control. Which of the following information should the nurse recommend to include?

Correct Answer is C

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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