A nurse is collecting data on a newborn who has experienced Duchenne-Erb (Erb's) palsy.
Which of the following manifestations should the nurse expect?
Absent Moro reflex, arm extended at the elbow and positioned against body with decreased grasp on affected side.
Asymmetry of the face during crying and drooping of the corner of the mouth on affected side.
Asymmetry of Moro reflex, arm externally rotated, and grasp reflex absent on affected side.
Asymmetry of Moro reflex, crepitus, no movement, swelling, and tenderness on palpation of affected arm.
The Correct Answer is A
Choice A rationale
Duchenne-Erb (Erb's) palsy is a type of brachial plexus injury that commonly results in an absent Moro reflex on the affected side, an extended arm at the elbow, and decreased grasp. These symptoms arise from injury to the fifth and sixth cervical nerves, leading to motor deficits.
Choice B rationale
This describes facial nerve palsy, not Erb's palsy. Facial nerve palsy affects the muscles of the face, leading to asymmetry during crying and drooping of the mouth's corner on the affected side.
Choice C rationale
While asymmetry of the Moro reflex is accurate, this choice incorrectly states that the arm is externally rotated and the grasp reflex is absent, which aligns more with a total brachial plexus injury rather than Erb's palsy.
Choice D rationale
Crepitus, no movement, swelling, and tenderness on palpation are indicative of a fracture rather than Erb's palsy. These symptoms suggest bone injury rather than nerve damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A hymenal tag and white discharge on the genitalia are normal findings in newborn females, often due to maternal hormone exposure.
Choice B rationale
Edema on the scalp that crosses suture lines, known as caput succedaneum, is common and typically resolves on its own without intervention.
Choice C rationale
A heart murmur in a newborn can be normal, as many murmurs are benign and resolve as the newborn's circulation adjusts post-birth.
Choice D rationale
A large, deep sacral dimple above the gluteal cleft can be an indication of underlying spinal abnormalities, such as spina bifida, and requires further evaluation.
Correct Answer is D
Explanation
Choice A rationale
The hearing screening test is not related to brain development but specifically to the ability to hear sounds. It assesses the infant's auditory pathway from the ear to the brainstem to identify potential hearing loss early on.
Choice B rationale
This test does not assess for heart defects. Heart defects are usually detected through physical examination, pulse oximetry screening, or echocardiography, not through auditory tests.
Choice C rationale
Seizure disorders are diagnosed based on clinical presentation and electroencephalogram (EEG) results. The hearing screening test does not have any connection to identifying seizure disorders.
Choice D rationale
The primary purpose of the newborn hearing screening is to detect if the baby can hear various sounds, enabling early intervention if hearing loss is detected. Early identification and management are essential for speech and language development.
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