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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Verifying the identity of anyone who wants to remove the baby from the room is crucial for ensuring the security and safety of the newborn. This helps prevent unauthorized individuals from taking the baby without proper authorization from the parents or healthcare staff.
B. Leaving the baby unattended in the room while the parent walks in the hallway can pose a safety risk, as the newborn should always be under supervision to prevent accidents or unauthorized access.
C. Newborns typically wear identification bands on both wrists to ensure accurate identification and prevent mix-ups in the hospital setting. Placing identification bands on other body parts may lead to confusion.
D. Leaving the unit with the baby without notifying the nurse can compromise the security measures in place and may lead to confusion or concern among hospital staff regarding the whereabouts of the newborn. It's important to communicate with healthcare providers before leaving the unit with the baby.

A. Massage areas around the edge of the client's cast with lotion. B. Avoid elevating the extremity when the client is resting in bed. C. Give the client a dull object to scratch the skin under the cast. D. Tell the client to report any numbness in their toes.

Correct Answer is D

Explanation

A. Massaging areas around the edge of the cast with lotion can introduce moisture and compromise the integrity of the cast, increasing the risk of skin breakdown and infection.
B. Elevating the extremity when the client is resting in bed helps reduce swelling and improve circulation, promoting healing. It is an appropriate action for a client with a cast.
C. Inserting objects under the cast can damage the skin, increase the risk of infection, or disrupt the integrity of the cast.

D. Numbness can indicate impaired circulation or nerve compression and warrants immediate assessment, making this the correct action.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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