A nurse is caring for a client who delivered a post-term infant vaginally with shoulder dystocia.
Which of the following findings should alert the nurse to possible injury in the infant?
Absent Moro reflex on the affected side.
Flaccid paralysis of both lower extremities.
Facial asymmetry when crying or smiling.
Inability to suck or swallow.
The Correct Answer is A
Absent Moro reflex on the affected side indicates a possible injury to the brachial plexus, which is the nerve network that controls the movements and sensations of the shoulder, arm, hand and fingers. Shoulder dystocia can cause brachial plexus injuries when the baby’s shoulder gets stuck behind the mother’s pubic bone during delivery.
Choice B is wrong because flaccid paralysis of both lower extremities is not a common complication of shoulder dystocia.
It could be a sign of spinal cord injury or other neurological disorders.
Choice C is wrong because facial asymmetry when crying or smiling is a sign of facial nerve palsy, which can occur due to compression of the facial nerve during delivery.
It is not specific to shoulder dystocia.
Choice D is wrong because inability to suck or swallow is not a typical sign of shoulder dystocia.
It could be caused by other factors such as prematurity, neurological problems, or congenital anomalies.
Normal ranges for Moro reflex are present at birth and disappear by 4 to 6 months of age.
Normal ranges for facial nerve function are symmetrical movements of both sides of the face.
Normal ranges for sucking and swallowing are coordinated and effective feeding within the first hour after birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is a sign of dehydration, which can be caused by phototherapy.Phototherapy increases insensible water loss through the skin and can lead to fluid and electrolyte imbalance in the newborn.The nurse should monitor the newborn’s hydration status, weight, urine output, and serum electrolytes and provide adequate fluid intake.
Choice A is wrong because conjunctivitis is not a common complication of phototherapy.It can be prevented by using eye shields or patches to protect the newborn’s eyes from the light source.
Choice B is wrong because bronze skin discoloration is a rare complication of phototherapy that occurs when the bilirubin level is very high and the skin pigment changes.It is not a priority finding and usually resolves after phototherapy is discontinued.
Choice D is wrong because maculopapular skin rash is a benign side effect of phototherapy that does not require intervention.It usually disappears within a few days after phototherapy is stopped.
Correct Answer is C
Explanation
Jitteriness and poor feeding are common signs of hypoglycemia in a newborn.
Hypoglycemia is when the level of sugar (glucose) in the blood is too low.
Glucose is the main source of fuel for the brain and the body.In a newborn baby, low blood sugar can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.
Choice A is wrong because hypertension and bradycardia are not typical symptoms of hypoglycemia in a newborn.
They may indicate other conditions such as heart problems or infection.
Choice B is wrong because diarrhea and vomiting are not specific symptoms of hypoglycemia in a newborn.
They may be caused by many other factors such as infection, food intolerance, or gastroesophageal reflux.
Choice D is wrong because hyperactivity and irritability are not usual symptoms of hypoglycemia in a newborn.
They may be signs of other conditions such as pain, hunger, or overstimulation.
Normal ranges for blood glucose levels in newborns vary depending on the age, gestational age, and feeding status of the baby.Most doctors consider blood glucose that is below 47 milligrams per deciliter (mg/dl) to be the definition of hypoglycemia in newborns.
However, some babies may need higher levels to prevent brain injury.
A doctor will monitor the blood glucose levels of a newborn at risk for hypoglycemia and treat accordingly.
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