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 C
Explanation
Choice A rationale
Infrequent or inconsistent feedings lead to milk stasis, providing an environment conducive to bacterial growth, which can result in mastitis. Proper breastfeeding frequency ensures milk drainage, reducing stasis and infection risk. Milk stasis is a primary contributor to the development of mastitis, emphasizing the importance of regular feeding practices.
Choice B rationale
Nipple cracks and fissures are a direct portal for bacterial entry, increasing the likelihood of infection in the lactiferous ducts. Staphylococcus aureus, commonly present on the skin, can invade through damaged tissue, resulting in mastitis. Proper nipple care and hygiene are essential in prevention.
Choice C rationale
Gradual weaning allows for a decrease in milk production, preventing engorgement and stasis, which reduces the risk of mastitis. Gradual weaning gives the mammary glands time to adapt. Mastitis is more commonly associated with abrupt changes in feeding patterns or milk stasis rather than controlled weaning processes.
Choice D rationale
Engorgement from oversupply creates increased intraductal pressure, which can lead to blocked ducts and milk stasis, creating conditions favorable for bacterial growth. Engorgement needs prompt management to prevent secondary infections such as mastitis, particularly in lactating individuals.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Accurate measurement of intake and output is crucial after atrial septal defect repair to detect potential fluid imbalances or kidney dysfunction. Monitoring ensures early intervention in cases of dehydration or fluid overload.
Choice B rationale
Providing uninterrupted rest promotes recovery by minimizing stress on the cardiovascular system and reducing metabolic demands post-surgery. Adequate rest also allows tissue healing and stabilizes vital parameters.
Choice C rationale
Maintaining a thermoneutral environment prevents temperature fluctuations, which could increase metabolic demand and stress the healing heart. Temperature regulation is particularly important in infants with compromised cardiac function.
Choice D rationale
Encouraging bonding supports emotional and psychological recovery for both the infant and parents. Physical closeness can improve the infant's developmental outcomes and reduce parental anxiety after surgery.
Choice E rationale
Using an incentive spirometer 10 times hourly is not appropriate for infants. Incentive spirometers are designed for cooperative patients, typically older children or adults, as they require active participation in deep-breathing exercises.
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