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.
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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Compartment syndrome occurs when there is increased pressure within a closed muscle compartment, leading to reduced blood flow to the muscles and nerves in that compartment. In this case, the open fracture and subsequent reduction and stabilization procedure can cause swelling and increased pressure within the affected compartment. This can impede blood flow and potentially lead to tissue damage. Common symptoms include severe pain, swelling, numbness, and decreased or absent pulses. Immediate medical attention is necessary if compartment syndrome is suspected.
Deep Vein Thrombosis (DVT) refers to the formation of blood clots within the deep veins, typically in the lower extremities. In the case of a client with an open fracture and immobilization with a splint, the risk of DVT increases due to factors such as reduced mobility, injury to blood vessels, and blood stasis. DVT can lead to serious complications if a clot dislodges and travels to the lungs, causing a pulmonary embolism. Symptoms of DVT may include pain, swelling, warmth, and redness in the affected limb.
While osteomyelitis and fat embolism syndrome can occur as complications of long bone fractures, they are not explicitly mentioned in the given scenario. Osteomyelitis refers to an infection in the bone, which can develop if bacteria enter an open fracture. Fat embolism syndrome can occur when fat globules from the bone marrow enter the bloodstream, usually following a long bone fracture.
Correct Answer is C
Explanation
A nurse reinforcing discharge teaching with the guardian of a client who is neutropenic should include the instruction to notify the provider if the child has a fever. A fever can be a sign of infection, which can be serious in a client who is neutropenic.
The other options are not correct.
A client who is neutropenic should avoid crowded places such as stores to reduce their risk of infection. The guardian should inspect the child's mouth daily, not weekly, for ulcers. A client who is neutropenic should avoid fresh fruits as they may carry bacteria that can cause infection.
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