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A nurse is caring for a newborn who is 4 hours old in the neonatal unit.

Exhibits

Complete the following sentence by using the list of options. Drag 1 condition and 1 client finding to fill in each blank in the following statement:

The newborn most likely has

as evidenced by .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

The newborn most likely has Brachial plexus injury (B) as evidenced by Left arm remains at the side during Moro reflex (B).

 

Choice A rationale:

Congenital cardiac defect is less likely since the newborn has a normal heart rate and oxygen saturation. There are no signs of respiratory distress beyond mild acrocyanosis, which is common in newborns and usually resolves without intervention.

 

Choice B rationale:

Brachial plexus injury is suggested by the newborn's inability to move the left arm during the Moro reflex. This type of injury is often associated with shoulder dystocia and vacuum-assisted delivery, which can stretch or damage the brachial plexus nerves.

 

Choice C rationale:

Fractured clavicle could be a possibility due to the shoulder dystocia, but it is less likely given that the only noted abnormal finding is the lack of movement in the left arm. Typically, a fractured clavicle would present with crepitus, swelling, or a palpable fracture.

 

Choice D rationale:

Neonatal sepsis is less likely as the newborn appears to be active, has a normal temperature, and no signs of systemic infection. The only abnormal findings are related to the left arm movement and caput succedaneum, which are more consistent with a birth injury rather than an infection.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale

A uterine contraction duration of 130 seconds is too long and indicates uterine hyperstimulation, which is not an effective outcome.

Choice B rationale

Uterine contraction frequency every three to four minutes is a normal and effective pattern, indicating that the nurse's intervention to stop oxytocin was successful.

Choice C rationale

The intensity of contractions being strong is important but does not directly indicate effective management of tachysystole.

Choice D rationale

Fetal flexed attitude refers to the fetal position and does not indicate the effectiveness of managing tachysystole.

Correct Answer is []

Explanation

The condition of imminent delivery is correct because the client, gravida 5 para 4 at 39 weeks gestation, is experiencing strong contractions and rectal pressure indicative of advanced labor stages. The physical examination supports active labor, with a firm, palpable uterus, and fetal heart rate present. The urgency of notifying the healthcare provider and encouraging bearing down aligns with labor management in advanced stages. Cervical dilation is essential to assess labor progression, and fetal heart rate monitoring ensures fetal well-being during delivery.

Actions and Parameters Rationale:

  1. Notifying the healthcare provider immediately ensures timely medical intervention, crucial for safe delivery and management of any complications.
  2. Encouraging the client to bear down with contractions aids the birthing process by utilizing the client’s natural efforts in the expulsion phase of labor.
  3. Monitoring cervical dilation provides insight into how far along the client is in labor, helping to anticipate the time of delivery.
  4. Continuous monitoring of fetal heart rate ensures the baby's well-being, detecting any distress during labor.

Incorrect Conditions:

  1. Preterm labor (A): The client is at 39 weeks gestation, so the labor is not preterm.
  2. Placental abruption (B): There are no signs of placental abruption, such as vaginal bleeding, uterine tenderness, or abnormal fetal heart rate patterns.
  3. Prolapsed umbilical cord (C): There is no indication of a prolapsed cord, such as sudden fetal distress or visible/palpable cord.

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