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:
Diminished deep-tendon reflexes are a sign of magnesium toxicity, not safety. Magnesium sulfate is a central nervous system depressant that can cause muscle weakness, respiratory depression, and cardiac arrest if given in excess. The nurse should monitor the client's deep-tendon reflexes and stop the infusion if they are absent or reduced.
Choice B reason:
A respiratory rate of 16/min is a normal finding and indicates that the client is not experiencing respiratory depression from magnesium sulfate. The nurse should monitor the client's respiratory rate and stop the infusion if it falls below 12/min.
Choice C reason:
A heart rate of 60/min is a normal finding and indicates that the client is not experiencing bradycardia from magnesium sulfate. The nurse should monitor the client's heart rate and stop the infusion if it falls below 50/min.
Choice D reason:
Urine output of 50 mL in 4 hr is a sign of oliguria, not safety. Magnesium sulfate can cause renal impairment and fluid retention if given in excess. The nurse should monitor the client's urine output and stop the infusion if it falls below 30 mL/hr.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:
Cerebral palsy is a disorder that affects movement, posture, and muscle tone. It can be caused by brain damage that occurs before, during, or after birth. Premature babies are at a higher risk of developing cerebral palsy because they are more likely to have bleeding in the brain, lack of oxygen to the brain, infections or other complications that can damage the brain.
Choice B reason:
Color blindness is a condition that affects the ability to see colors or differences in colors. It is usually inherited and not related to prematurity. However, some premature babies may develop retinopathy of prematurity, which can affect their vision in other ways.
Choice C reason:
Learning disabilities are problems that affect the ability to learn, read, write, speak or do math. They can be caused by genetic factors, environmental factors or brain injuries.
Premature babies are more likely to have learning disabilities because they are more likely to have brain damage, low birth weight, infections or other complications that can affect their brain development.
Choice D reason:
Retinopathy is a disease that affects the blood vessels in the retina, the light-sensitive layer of tissue at the back of the eye. Retinopathy of prematurity is a condition that occurs when the blood vessels in the retina grow abnormally in premature babies. This can cause bleeding, scarring or detachment of the retina, which can lead to vision loss or blindness.
Choice E reason:
Apnea is a condition that causes pauses in breathing during sleep. Apnea of prematurity is a condition that affects premature babies who have not fully developed their nervous system and respiratory system. This can cause them to stop breathing for more than 20 seconds at a time, which can lower their oxygen levels and heart rate.
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