A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?
Lip-smacking
Stiff posture
Weak cry
Tongue-darting
The Correct Answer is C
A. Lip-smacking may indicate hunger or a desire to feed but is not necessarily indicative of pain in a newborn with shoulder dystocia.
B. Stiff posture may indicate discomfort or distress, but it is not specific to pain and can be caused by various factors.
C. A weak cry can be a sign of pain or distress in newborns. It may indicate that the newborn is experiencing discomfort related to the shoulder dystocia.
D. Tongue-darting is a normal reflex in newborns and is not typically associated with pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.
Correct Answer is A
Explanation
A. Correct. Providing the client with a one-week supply of insulin syringes ensures they have the necessary equipment to administer insulin independently at home. This supports the client's independence while managing their diabetes.
B. Incorrect. While home health visits may be appropriate for some clients with diabetes, arranging daily visits may not be necessary for an independent client who is capable of managing their condition on their own.
C. Incorrect. Notifying the family of the client's health status may be appropriate in certain situations, but it is not essential for an independent client who is capable of managing their diabetes independently.
D. Incorrect. While joining a diabetic support group can be beneficial for many individuals with diabetes, it may not be necessary for all clients, especially those who are independent and prefer to manage their condition on their own.
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