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 D
Explanation
Phototherapy is a treatment that uses light to break down bilirubin in the blood and make it easier for the liver to eliminate it.
Phototherapy is effective when:
• The bilirubin levels decrease within 24 hours of treatment.
This means that the bilirubin is being cleared faster than it is being produced.
• The urine output and stool frequency increase during treatment.
This means that the bilirubin is being excreted through the kidneys and intestines.
• The skin color and muscle tone improve after treatment.
This means that the bilirubin is no longer causing jaundice or affecting the nervous system.
Statement A is wrong because it only describes one aspect of phototherapy effectiveness.
Statement B is wrong because it only describes another aspect of phototherapy effectiveness.
Statement C is wrong because it only describes the outcome of phototherapy effectiveness.
Statement D is correct because it includes all three aspects of phototherapy effectiveness.
Correct Answer is B
Explanation
Institute contact precautions.This is because the infant may havenecrotizing enterocolitis (NEC), which is the most common cause of bloody stool in preterm infants.
NEC is a serious condition that involves inflammation and necrosis of the intestinal wall and can lead to perforation, sepsis, and death.NEC is also a potential source of infection for other infants in the NICU, so contact precautions are necessary to prevent cross-contamination.
Choice A is wrong because obtaining a rectal temperature is not indicated for an infant with bloody stool.Rectal temperature can cause irritation and bleeding of the rectal mucosa and can also increase the risk of perforation if there is intestinal necrosis.
Choice C is wrong because decreasing the amount of the feeding is not enough to manage an infant with bloody stool.
The infant may need to have the feeding stopped completely and receive parenteral nutrition until the bowel heals.Decreasing the feeding may also compromise the infant’s growth and development.
Choice D is wrong because assessing for abdominal distention is not a nursing action but a nursing assessment.
Abdominal distention is a common sign of feeding intolerance and NEC, but it is not specific or sensitive enough to diagnose the condition.Other signs and symptoms of NEC include bile-stained or bloody gastric residuals, emesis, diarrhea, temperature instability, apnea, bradycardia, hypotension, and lethargy.
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