A nurse is caring for a newborn who is 4 hours old in the newborn unit.
Complete the following sentence by using the list of options: The newborn most likely has
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Given the provided information, here is the completion of the sentence using the options:
The newborn most likely has Brachial plexus injury as evidenced by Asymmetrical Moro reflex.
This conclusion is drawn from the observation that the newborn does not move the left arm during the Moro reflex, which is indicative of a possible brachial plexus injury. This type of injury can occur during childbirth, especially in cases involving shoulder dystocia and vacuum-assisted delivery.
The reason for diagnosing the newborn with a brachial plexus injury is based on the observation that the newborn does not move the left arm during the Moro reflex. The Moro reflex, also known as the startle reflex, is a normal response in newborns where they spread out their arms and then bring them back towards the body when they feel a sudden loss of support. In this case, the newborn is only moving one arm, which suggests that there might be an injury to the nerves that control movement in the affected arm.
Brachial plexus injuries often occur during difficult births, such as those involving shoulder dystocia and vacuum-assisted deliveries. These types of injuries can lead to weakness or paralysis of the affected arm. Given the details of the newborn's birth and the absence of movement in the left arm during the Moro reflex, a brachial plexus injury is the most likely condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A boggy and displaced fundus typically indicates bladder distention. Assisting the client to void can help relieve bladder distention, allowing the uterus to contract properly and reducing the risk of postpartum hemorrhage.
Choice B rationale
Asking the client to rate her pain is important, but it does not address the immediate issue of a boggy, displaced fundus, which suggests bladder distention.
Choice C rationale
Encouraging the client to move to the left lateral position might help with blood flow and comfort but does not resolve the issue of a boggy fundus due to bladder distention.
Choice D rationale
Kegel exercises strengthen pelvic floor muscles but do not address the immediate concern of a boggy, displaced fundus caused by bladder distention.
Correct Answer is C
Explanation
Choice A rationale
Accelerations are increases in the fetal heart rate (FHR) above the baseline, typically in response to fetal movement or uterine contractions. They indicate a healthy, well-oxygenated fetus and are not consistent with the described pattern of decelerations.
Choice B rationale
Late decelerations are characterized by a gradual decrease in FHR that begins after the contraction has started, with the lowest point of the deceleration (nadir) occurring after the peak of the contraction. They are associated with uteroplacental insufficiency and fetal hypoxia, which is not described in the scenario.
Choice C rationale
Early decelerations are a gradual decrease in FHR that mirrors the contraction, starting with the contraction and returning to baseline as the contraction ends. The nadir of the deceleration occurs at the peak of the contraction, which fits the pattern described.
Choice D rationale
Variable decelerations are abrupt decreases in FHR that can occur at any time during the contraction cycle, usually due to umbilical cord compression. They are not uniform in relation to contractions and can vary in duration, depth, and timing, unlike the described pattern.
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