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
While pelvic inflammatory disease can lead to infertility, it does not specifically cause endometriosis. PID involves infection of the reproductive organs, while endometriosis is the presence of endometrial tissue outside the uterus, characterized by pain and inflammation during menstruation.
Choice B rationale
An atypical Papanicolaou smear indicates abnormal cervical cells, often related to infection or precancerous changes, but is not indicative of endometriosis. Endometriosis involves ectopic endometrial tissue and does not affect cervical cell morphology directly.
Choice C rationale
Dysmenorrhea unresponsive to NSAIDs is a hallmark of endometriosis. This condition causes severe pain due to the inflammation and cyclic bleeding of ectopic endometrial tissue, often resulting in scarring and adhesions that exacerbate discomfort during menstruation.
Choice D rationale
Abdominal bloating starting before menses may be associated with premenstrual syndrome or other hormonal changes rather than endometriosis. Although some women with endometriosis report bloating, it is not a definitive diagnostic criterion compared to chronic pain and infertility.
Correct Answer is A
Explanation
Choice A rationale
Reporting to a child abuse hotline is a priority intervention when there is a suspicion of non-accidental trauma, such as a spiral fracture in a non-ambulatory infant. Spiral fractures are highly indicative of twisting injuries, which are unlikely to result from a fall and suggest possible abuse.
Choice B rationale
Educating the mother on safety is an important intervention for accidental injuries but does not address the immediate concern of potential abuse. The focus should be on investigating the cause of the injury to ensure the child’s safety.
Choice C rationale
Informing the mother to call the nurse for all diaper changes is not relevant to investigating potential abuse. This action fails to prioritize the safety and protection of the child in cases where abuse is suspected.
Choice D rationale
Completing the Morse Fall Scale assesses fall risk and is not appropriate for investigating the etiology of the injury. It does not address the immediate need to ensure the child’s safety or initiate an investigation into possible abuse.
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