A newborn is delivered vaginally after a prolonged second stage of labor with the use of forceps. Upon assessment, the nurse notes weak movement of the left arm, absent Moro reflex on that side, and intact grasp reflex. Which birth injury should the nurse suspect?
Erb's palsy
Facial nerve injury
Cephalohematoma
Caput succedaneum
The Correct Answer is A
A. The combination of weak arm movement, absent Moro reflex, and intact grasp reflex directly points to an upper brachial plexus injury, consistent with Erb’s palsy. Immediate management includes supportive care, gentle range-of-motion exercises, and referral to a pediatric neurologist or physical therapist. Early intervention improves functional outcomes and reduces long-term disability.
B. Caput succedaneum is diffuse edema of the scalp caused by pressure during delivery, often crossing suture lines. It is benign, self-limiting, and does not affect limb movement or reflexes. The infant’s motor deficits are not explained by caput succedaneum.
C. Cephalohematoma is a localized subperiosteal blood collection, typically limited by suture lines. It presents as a firm scalp swelling, sometimes with jaundice as a complication. Cephalohematoma does not cause limb weakness or absent reflexes, so it is inconsistent with the findings in this case.
D. Facial nerve injury during birth, often due to traction or forceps application on the face, manifests as facial asymmetry, inability to close the eyelid, drooping of the mouth, or absent nasolabial fold. It does not affect arm movement or the Moro reflex, so it cannot account for the infant’s symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Rho(D) immune globulin (RhoGAM) is indicated when an Rh-negative mother gives birth to an Rh-positive infant. This prevents the mother’s immune system from developing antibodies against Rh-positive blood cells, which could cause hemolytic disease of the newborn (HDN) in future pregnancies.
B. An Rh-positive mother already has the D antigen, so she will not form antibodies against an Rh-negative baby. RhoGAM is not needed.
C. The mother is Rh-positive and cannot develop antibodies against Rh-positive fetal blood cells. No RhoGAM is required.
D. Both mother and baby are Rh-negative, so there is no risk of maternal sensitization. RhoGAM is not indicated.
Correct Answer is D
Explanation
A. Hydralazine is an antihypertensive used to manage severe hypertension in preeclampsia. While controlling blood pressure is essential in preeclampsia, hydralazine does not reverse the toxic effects of magnesium. Administering hydralazine in this context would not address the immediate life-threatening neuromuscular or respiratory depression.
B. Methylergonovine is a uterotonic agent used to treat postpartum hemorrhage by stimulating uterine contractions. It has no effect on magnesium toxicity and is unrelated to seizure prophylaxis or respiratory function. Administering this drug would not correct the client’s critical condition.
C. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Magnesium sulfate toxicity is not opioid-related, so Narcan would not improve respiratory rate, restore reflexes, or address neuromuscular blockade caused by magnesium.
D. Calcium gluconate is the specific antidote for magnesium sulfate toxicity. It works by antagonizing the effects of magnesium at the neuromuscular junction, restoring deep tendon reflexes, and improving respiratory muscle function. Administration is intravenous, slow, and under close monitoring. Simultaneously, the magnesium infusion should be stopped immediately to prevent further accumulation. After stabilization, the nurse should monitor vital signs, urine output, reflexes, and serum magnesium levels to ensure safe recovery.
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