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 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.

Exchange transfusion (ET) is a procedure that involves removing the infant’s blood and replacing it with compatible donor blood to reduce the level of bilirubin and/or antibody-coated red blood cells.It is a high-risk intervention that can cause serious complications such as vascular accidents, cardiovascular compromise, and electrolyte and hematologic derangement.

Therefore, it is essential to obtain informed consent from the parent before performing ET.

Choice B is wrong because checking the newborn’s blood type and crossmatch is not the first action the nurse should take.

Although it is important to ensure compatibility between the donor and recipient blood, it is not as urgent as obtaining informed consent.

Choice C is wrong because inserting two umbilical catheters for blood withdrawal and infusion is not the first action the nurse should take.

Although it is necessary to establish vascular access for ET, it is not as crucial as obtaining informed consent.

Choice D is wrong because monitoring the newborn’s vital signs and oxygen saturation is not the first action the nurse should take.

Although it is vital to assess the newborn’s condition before, during, and after ET, it is not as imperative as obtaining informed consent.

Normal ranges for bilirubin levels vary depending on the gestational age and postnatal age of the newborn.The American Academy of Pediatrics (AAP) has published nomograms for initiating phototherapy and ET based on these factors.According to the AAP, ET should be considered when the bilirubin level exceeds 25 mg/dL (428 μmol/L) in term infants or 20 mg/dL (342 μmol/L) in preterm infants with risk factors for neurotoxicity.