A 2-month-old infant is brought to the emergency room.
Which factor should lead the RN to suspect that the child may have experienced abusive head trauma?
Sunken fontanels.
Retinal hemorrhage.
Large bruises on the body.
Laceration to the forearm.
The Correct Answer is B
Choice A rationale
Sunken fontanels are typically a sign of dehydration due to reduced intracranial pressure and are not specific to abusive head trauma. Abusive head trauma often results in elevated intracranial pressure or swelling, which would present differently. Therefore, this finding is unrelated to the mechanisms of abusive head trauma in a 2-month-old.
Choice B rationale
Retinal hemorrhages are strongly associated with abusive head trauma due to the shearing forces during shaking or impact, which rupture retinal blood vessels. This finding is a hallmark of non-accidental trauma in infants, as accidental injuries rarely cause this degree of internal ocular damage.
Choice C rationale
Large bruises on the body could indicate trauma but are not specific to abusive head trauma. Additionally, the pattern or location of bruises is significant for abuse, especially in non-mobile infants. However, bruises alone do not confirm head trauma specifically.
Choice D rationale
Lacerations, such as those on the forearm, might suggest trauma but lack specificity for abusive head trauma. Such injuries are more commonly associated with accidents or other forms of physical abuse that do not necessarily involve the head.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Elevated AFP levels are not typically associated with Down syndrome. In fact, pregnancies with Down syndrome often show decreased levels of AFP in maternal serum screening. AFP is a protein produced by the fetal liver, and its levels vary depending on developmental abnormalities like neural tube defects, not chromosomal disorders like Down syndrome.
Choice B rationale
Elevated AFP levels in a pregnant patient indicate potential neural tube defects such as spina bifida. Spina bifida results from incomplete closure of the fetal neural tube during early pregnancy, leading to exposure of neural tissues. AFP leaks into the maternal serum through this defect, thus raising its concentration significantly, which serves as a marker.
Choice C rationale
AFP levels are generally low in cases of Down syndrome due to chromosomal anomalies. Trisomy 21 pregnancies display distinctive serum markers, including decreased AFP. Elevated AFP does not signify Down syndrome because the pathology involves a different spectrum of physiological abnormalities.
Choice D rationale
While spina bifida is indeed a condition associated with elevated AFP, this statement is less accurate due to the phrasing. AFP elevations serve as an indicator rather than definitive confirmation of spina bifida. Further diagnostic tests like ultrasonography or amniocentesis are needed to confirm the condition.
Correct Answer is ["C"]
Explanation
Choice A rationale
Assessing the baseline fetal heart rate (FHR) over a 10-minute period ensures accurate measurement by capturing rate fluctuations due to fetal activity or maternal factors. This duration is a standardized method to establish a representative baseline. Variability is excluded during this time, focusing on a stable resting rate.
Choice B rationale
Baseline FHR can be obtained using ultrasound or auscultation, both being reliable non-invasive methods for assessing fetal well-being. These tools accurately detect cardiac activity and provide real-time data, allowing consistent monitoring during labor.
Choice C rationale
Baseline FHR cannot be obtained during contractions due to transient accelerations or decelerations caused by uterine compression. These changes do not represent the resting heart rate. Accurate baseline assessments require a period without uterine activity to avoid skewed results.
Choice D rationale
A normal FHR of 110-160 bpm indicates adequate oxygenation and neural regulation. This range reflects the fetal cardiovascular system's ability to adapt to in utero conditions. Values outside this range might suggest hypoxia, infection, or other abnormalities.
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