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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Nevus flammeus is a port-wine stain, a type of birthmark that is present at birth and does not fade over time. It is caused by a malformation of capillaries in the skin and appears as a reddish-purple patch. It can occur anywhere on the body but is not associated with swelling or suture lines.
Choice B reason:
Cephalhematoma is a collection of blood under the periosteum of the skull bone, usually caused by trauma during delivery. It appears as a swollen area on the head that does not cross the suture line because it is limited by the boundaries of the bone. It usually resolves within a few weeks or months without treatment.
Choice C reason:
Molding is the temporary change in the shape of the newborn's head due to the pressure of the birth canal during delivery. It results in an elongated or cone-shaped head that may cross the suture line. It usually resolves within a few days as the skull bones return to their normal position.
Choice D reason:
Caput succedaneum is a localized swelling of the scalp, usually caused by pressure from the cervix or vacuum extraction during delivery. It appears as a soft, puffy area on the head that crosses the suture line because it is not limited by the bone. It usually resolves within a few days without treatment.
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.
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