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 B
Answer: B. Stiff posture
Rationale:
A. Lip-smacking : Lip-smacking is not typically an indication of pain in newborns. It may be associated with hunger or neurological responses, but it does not directly indicate discomfort or pain caused by shoulder dystocia or other injuries.
B. Stiff posture : A stiff posture can indicate pain in newborns, as they often exhibit hypertonicity or rigidity when experiencing discomfort. This response is a protective mechanism and may suggest the newborn is reacting to pain from potential nerve or tissue damage caused by shoulder dystocia.
C. Weak cry : While a weak cry may indicate neurological or respiratory distress, it is not a specific sign of pain. In the context of shoulder dystocia, a weak cry could reflect complications such as brachial plexus injury but does not directly signify the presence of pain.
D. Tongue-darting : Tongue-darting is more commonly associated with neurological issues or feeding difficulties rather than pain. It is not a typical behavioral response to discomfort or injury in newborns experiencing complications like shoulder dystocia.
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Related Questions
Correct Answer is D
Explanation
d. Increased joint stiffness due to loss of elasticity in joint cartilage.
Explanation:
The correct answer is d. Increased joint stiffness due to loss of elasticity in joint cartilage.
When teaching an older adult client about age-related changes, it is important for the nurse to provide accurate and relevant information. Joint stiffness is a commonly experienced age-related change that occurs due to the natural loss of elasticity in joint cartilage. As people age, their joints may become stiffer and less flexible, making movements and activities more challenging.
Option a is not the correct answer. Increased nail growth due to the buildup of calcium deposits is not an expected age-related change. Nail growth is primarily determined by factors such as genetics, overall health, and nutritional status, rather than calcium deposits.
Option b is not the correct answer. Increased perspiration due to overproduction by the sweat glands is not an expected age-related change. In fact, older adults may experience a decrease in the production of sweat, which can make them more susceptible to heat-related illnesses and dehydration.
Option c is not the correct answer. Increased cardiac output due to weakened heart walls is not an expected age-related change. With aging, the heart muscles may become stiffer and less efficient, leading to a decrease in cardiac output rather than an increase.
By focusing on the expected age-related change of increased joint stiffness due to loss of elasticity in joint cartilage, the nurse can provide accurate information and help the older adult client understand and manage this common aspect of the aging process.
Correct Answer is A
Explanation
Answer: A. Potassium
Rationale:
A) Potassium:
Furosemide is a loop diuretic that can cause significant potassium loss through increased urine output. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to serious cardiac arrhythmias and muscle weakness. Ensuring potassium levels remain within a normal range helps maintain the infant's overall health and safety while on this medication.
B) WBC Count:
While it is important to monitor WBC count in various clinical situations, furosemide does not typically affect white blood cell levels. Therefore, monitoring WBC count is not specifically indicated for infants receiving furosemide unless there is another underlying condition that requires it.
C) Iron:
Iron levels are not typically affected by furosemide. Monitoring iron levels would be more relevant in cases of anemia or other hematologic conditions. Furosemide does not interfere with iron metabolism, so this test is not a priority for infants on this medication.
D) Amylase:
Amylase is an enzyme related to the pancreas and is typically monitored in conditions such as pancreatitis. Furosemide does not have a direct effect on amylase levels, so monitoring this enzyme is not necessary for infants receiving this diuretic. The focus should be on electrolytes, particularly potassium.
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