Which assessment findings may cause the nurse to suspect a brachial plexus injury?

The newborn has hypotonia

The newborn does not demonstrate the Moro reflex

The newborn cries continually

The newborn has tremors

Answer and Explanation

The Correct Answer is B

Choice A reason:

The newborn has hypotonia. This is not a specific sign of brachial plexus injury, as hypotonia can have many other causes, such as genetic disorders, infections, or brain damage.

Hypotonia is a general term for low muscle tone or weakness, which can affect the whole body or specific parts.

Choice B reason:

The newborn does not demonstrate the Moro reflex. This is a sign of brachial plexus injury, especially if it affects only one arm. The Moro reflex is a startle response that causes the baby to throw out the arms and legs, then curl them in when startled. A brachial plexus injury can impair the nerve function in the shoulder, arm, or hand, leading to decreased movement or sensation in the upper extremity. If the baby does not show the Moro reflex on one side, it may indicate damage to the upper brachial plexus nerves (C5-C7), also known as Erb's palsy.

Choice C reason:

The newborn cries continually. This is not a specific sign of brachial plexus injury, as crying can have many other causes, such as hunger, discomfort, or colic. Crying is a normal way for babies to communicate their needs and feelings. Crying does not necessarily indicate pain from a brachial plexus injury, as infants' nerves behave differently from adults' and they may not experience much pain from this condition.

Choice D reason:

The newborn has tremors. This is not a specific sign of brachial plexus injury, as tremors can have many other causes, such as cold temperature, low blood sugar, or withdrawal from maternal medications. Tremors are involuntary movements of the muscles that can affect the whole body or specific parts. Tremors do not necessarily indicate nerve damage from a brachial plexus injury, as this condition usually causes weakness or paralysis of the affected muscles.

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Correct Answer is C

Explanation

Choice A reason:

This statement does not indicate inhibition of parental attachment. The client may have prior experience or knowledge of bathing a newborn and may not need the demonstration. The nurse should respect the client's autonomy and confidence in this skill.

Choice B reason:

This statement does not indicate inhibition of parental attachment. The client may be exhausted from the labor and delivery process and may need some rest to recover. The nurse should support the client's request and ensure that the newborn is well cared for in the nursery.

Choice C reason:

This statement indicates inhibition of parental attachment. The client expresses dissatisfaction with the newborn's appearance and implies that the newborn is not attractive enough. The nurse should explore the client's feelings and expectations about the newborn and provide reassurance and education about normal variations in newborn features.

Choice D reason:

This statement does not indicate inhibition of parental attachment. The client recognizes a family resemblance in the newborn and expresses a positive connection with the newborn and the partner. The nurse should acknowledge the client's observation and encourage further bonding with the newborn.

A. Tremors B. Newborn rash C. Cephalohematoma D. Acrocyanosis

Correct Answer is C

Explanation

Choice A reason:

Tremors are not a sign of hyperbilirubinemia, but they may indicate other problems such as hypoglycemia, hypocalcemia, or seizures. Tremors are involuntary muscle movements that can affect different parts of the body.

Choice B reason:

Newborn rash, also known as erythema toxicum, is a common and harmless skin condition that affects many newborns. It causes red spots with white or yellow centers on the face, chest, back, or limbs. It is not related to hyperbilirubinemia or liver function.

Choice C reason:

Cephalohematoma is a collection of blood under the scalp that occurs due to trauma during delivery. It can increase the risk of hyperbilirubinemia because the breakdown of red blood cells in the hematoma releases bilirubin into the bloodstream. Bilirubin is a yellow pigment that is normally processed by the liver and excreted in stool and urine. If the liver is overwhelmed by the amount of bilirubin, it can cause jaundice, which is yellowing of the skin and eyes.

Choice D reason:

Acrocyanosis is a bluish discoloration of the hands and feet that occurs in some newborns due to poor circulation. It is usually a normal and transient phenomenon that does not indicate any serious problem. It is not a sign of hyperbilirubinemia or liver dysfunction.

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Which assessment findings may cause the nurse to suspect a brachial plexus injury?

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