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

- Rationale for A: Serving meals with plastic utensils is a safety measure to prevent self-harm. Metal utensils can be used as weapons, so plastic is a safer alternative. This action reflects the priority of maintaining a safe environment for the client.
- Rationale for B: Assigning another client to accompany the client to therapy sessions is not advisable. It may violate privacy and confidentiality, and it is not the responsibility of other clients to monitor safety.
- Rationale for C: Assigning the client to a private room could be beneficial for monitoring purposes, but it does not directly prevent self-harm. It is also important to consider that constant observation is necessary regardless of room assignment.
- Rationale for D: Checking on the client every 4 hours is not sufficient for a client who is at high risk for suicide. More frequent monitoring is needed to ensure the client's safety and to intervene promptly if necessary.

A. "A nurse will insert an IV prior to starting the test." B. "You should have nothing to eat or drink for 4 hours prior to the test." C. "You should expect the test to take a minimum of 2 hours." D. "You will be asked to press a button when you feel your baby move." E. "You will be asked to press a button when you feel your baby move."

Correct Answer is D

Explanation

A. Inserting an IV is not necessary for a nonstress test, which is a noninvasive procedure.
B. Fasting is not required for a nonstress test, as it does not involve any invasive procedures.
C. C. A nonstress test typically takes around 20 to 30 minutes to complete, not a minimum of 2 hours.
D. This is the correct answer. During a nonstress test, the client is asked to press a button every time they feel their baby move. This helps correlate fetal movements with changes in fetal heart rate, providing information about fetal well-being.

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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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