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 D
Explanation
Choice A rationale
Phototherapy is a treatment for jaundice but is not a preventive measure. It is used after jaundice has been identified to reduce bilirubin levels in the newborn.
Choice B rationale
Suctioning excess mucus with a bulb syringe helps clear the newborn’s airways but does not have a direct role in preventing jaundice. Jaundice is related to bilirubin metabolism, not mucus accumulation.
Choice C rationale
Preparing for an exchange blood transfusion is an intervention for severe hyperbilirubinemia but is not a preventive measure for jaundice. It is used when bilirubin levels are extremely high.
Choice D rationale
Initiating early feeding helps to promote bowel movements, which assists in the excretion of bilirubin from the body. This is an effective preventive measure for jaundice, as it helps reduce the chances of bilirubin buildup.
Correct Answer is A
Explanation
Choice A rationale
A newborn who is 26 hours post-delivery and has had no urine output needs immediate attention. Lack of urine output for over 24 hours may indicate dehydration or renal issues. Immediate medical evaluation is required to identify underlying conditions and prevent complications such as acute kidney injury or sepsis.
Choice B rationale
Acrocyanosis, characterized by blueish discoloration of the extremities, is common in newborns during the first 24-48 hours of life and usually resolves on its own. It occurs due to immature blood circulation and is generally not a cause for concern.
Choice C rationale
Failure to pass meconium within the first 24 hours can be a sign of conditions like Hirschsprung's disease or cystic fibrosis, but it is not as immediately concerning as anuria (no urine output). Monitoring and further evaluation are necessary, but it does not require urgent provider notification.
Choice D rationale
A blood glucose level of 50 mg/dL in a newborn is within the lower limit of normal. While it's important to monitor, it does not necessitate immediate provider notification unless it continues to drop or other symptoms arise.
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