A 2-month-old is brought into the emergency room. Which factor leads the RN to suspect abusive head trauma?
Sunken fontanels
Retinal hemorrhage
Laceration to forearm.
Large bruises on the body
The Correct Answer is B
A. Sunken fontanels: Sunken fontanels are typically associated with dehydration rather than abusive head trauma.
B. Retinal haemorrhage: Retinal haemorrhages are a key indicator of abusive head trauma, such as shaken baby syndrome. They are caused by the shearing forces of rapid acceleration and deceleration.
C. Laceration to forearm: While concerning, a laceration to the forearm is not specific to abusive head trauma and could result from various types of trauma.
D. Large bruises on the body: While large bruises might indicate physical abuse, they are not specific to head trauma and do not point as directly to abusive head trauma as retinal haemorrhages do.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The elevated AFP means my baby may have Down Syndrome. AFP is not typically elevated in Down Syndrome; other tests like nuchal translucency or cell-free DNA are used for that.
B. The elevated AFP means my baby may have spina bifida. AFP screening is used to detect neural tube defects like spina bifida. An elevated AFP level suggests a higher risk for such conditions.
C. The elevated AFP means my baby has Down syndrome. This is incorrect; AFP is not a marker for Down Syndrome.
D. The elevated AFP means my baby has spina bifida. This is correct, but option B is a more precise statement of understanding.
Correct Answer is C
Explanation
A. Umbilical cord compression. This typically results in variable decelerations, not late decelerations.
B. Fetal head compression. This is usually associated with early decelerations.
C. Uteroplacental insufficiency. Late decelerations occur after the peak of contractions and are indicative of insufficient blood flow and oxygen to the fetus, suggesting a problem with the placenta's ability to provide adequate oxygen.
D. Maternal bradycardia. Maternal bradycardia does not cause fetal decelerations.
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