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
Bronchospasm.
Bronchospasm is a constriction of the airways that causes wheezing and trouble breathing.It is one of the symptoms of anaphylaxis, a severe allergic reaction that can occur within minutes of exposure to something you’re allergic to, such as a bee sting.
Choice A is wrong because bradycardia is a slow heart rate, not a fast one.Anaphylaxis causes a weak and rapid pulse due to low blood pressure.
Choice B is wrong because hypertension is high blood pressure, not low.Anaphylaxis causes blood pressure to drop suddenly and can lead to shock.
Choice D is wrong because warm, dry skin is not a sign of anaphylaxis.Anaphylaxis causes skin reactions such as hives, itching, flushed or pale skin.
Correct Answer is A
Explanation
This is because newborns with hypoglycemia need to receive adequate nutrition to raise their blood glucose levels and prevent neurologic damage.Early feeding also helps establish breast milk supply for nursing mothers.
Choice B is wrong because feeding the baby only when he cries may delay the intake of glucose and worsen the hypoglycemia.Newborns with hypoglycemia should be fed on demand or at least every 2 to 3 hours.
Choice C is wrong because feeding the baby every 6 hours is too infrequent and may cause prolonged hypoglycemia.Newborns with hypoglycemia should be fed on demand or at least every 2 to 3 hours.
Choice D is wrong because feeding the baby with glucose water may not provide enough calories and nutrients for growth and development.Newborns with hypoglycemia should be fed with breast milk or formula.Glucose water may be used as a temporary measure until breast milk or formula is available.
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