Which assessment findings may cause the nurse to suspect a brachial plexus injury?
The newborn has hypotonia
The newborn does not demonstrate the Moro reflex
The newborn cries continually
The newborn has tremors
The Correct Answer is B
Choice A reason:
The newborn has hypotonia. This is not a specific sign of brachial plexus injury, as hypotonia can have many other causes, such as genetic disorders, infections, or brain damage.
Hypotonia is a general term for low muscle tone or weakness, which can affect the whole body or specific parts.
Choice B reason:
The newborn does not demonstrate the Moro reflex. This is a sign of brachial plexus injury, especially if it affects only one arm. The Moro reflex is a startle response that causes the baby to throw out the arms and legs, then curl them in when startled. A brachial plexus injury can impair the nerve function in the shoulder, arm, or hand, leading to decreased movement or sensation in the upper extremity. If the baby does not show the Moro reflex on one side, it may indicate damage to the upper brachial plexus nerves (C5-C7), also known as Erb's palsy.
Choice C reason:
The newborn cries continually. This is not a specific sign of brachial plexus injury, as crying can have many other causes, such as hunger, discomfort, or colic. Crying is a normal way for babies to communicate their needs and feelings. Crying does not necessarily indicate pain from a brachial plexus injury, as infants' nerves behave differently from adults' and they may not experience much pain from this condition.
Choice D reason:
The newborn has tremors. This is not a specific sign of brachial plexus injury, as tremors can have many other causes, such as cold temperature, low blood sugar, or withdrawal from maternal medications. Tremors are involuntary movements of the muscles that can affect the whole body or specific parts. Tremors do not necessarily indicate nerve damage from a brachial plexus injury, as this condition usually causes weakness or paralysis of the affected muscles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Protamine sulfate is an antidote for heparin overdose, not magnesium sulfate toxicity.
Choice B reason:
Naloxone is an antidote for opioid overdose, not magnesium sulfate toxicity.
Choice C reason:
Flumazenil is an antidote for benzodiazepine overdose, not magnesium sulfate toxicity.
Choice D reason:
Calcium gluconate is the antidote for magnesium sulfate toxicity. Magnesium sulfate is used to treat preeclampsia and prevent seizures, but it can cause respiratory depression, hypotension, and cardiac arrhythmias if given in excess. Calcium gluconate reverses the effects of magnesium by stabilizing the cell membrane and increasing the contractility of the heart.
Correct Answer is C
Explanation
Choice A reason:
Hypertonia is not a characteristic of a preterm infant, but rather of a post-term infant. Hypertonia means increased muscle tone or stiffness, which is more common in infants who are overdue. Preterm infants have poor muscle tone and less subcutaneous fat.
Choice B reason:
Long toenails are also not a characteristic of a preterm infant but of a post-term infant. Long toenails indicate that the infant has grown beyond the expected gestational age. Preterm infants have short and brittle nails.
Choice C reason:

Lanugo is a characteristic of a preterm infant. Lanugo is fine, downy hair that covers the body of the fetus. It usually disappears by the 36th week of gestation, but preterm infants may still have it at birth.
Choice D reason:
Dry skin is not a characteristic of a preterm infant but of a post-term infant. Dry skin indicates that the infant has lost moisture and subcutaneous fat due to prolonged exposure to the amniotic fluid. Preterm infants have thin and transparent skin that may be covered by vernix caseosa, a white, cheesy substance that protects the skin from the amniotic fluid.
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