A nurse is caring for a newborn who is 4 hr old.<\/p>\n\n\n\n
Nurses’ Notes<\/p>\n\n\n\n
Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
Newborn’s respirations are shallow and irregular.<\/p>\n\n\n\n
Newborn’s skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
Breastfed vigorously for 30 min.<\/p>\n\n\n\n
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.<\/p>\n\n\n\n
The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect<\/p>\n\n\n\n
The Correct Answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n The newborn most likely has a clavicle fracture<\/strong> as evidenced by left arm remains at side during Moro reflex<\/strong>.<\/p>\n\n\n\n Condition: Clavicle Fracture<\/strong><\/p>\n\n\n\n A clavicle fracture, often occurring during birth, is a common injury in newborns. This injury can result from the baby’s shoulder getting stuck in the birth canal or from the application of excessive force during delivery.<\/p>\n\n\n\n Client Finding: Left Arm Remains at Side During Moro Reflex<\/strong><\/p>\n\n\n\n One of the hallmark signs of a clavicle fracture in a newborn is limited movement or a noticeable lack of movement in one arm. This occurs because the fracture can cause pain and reduced mobility in the affected arm. During the Moro reflex (startle reflex), a healthy newborn will typically extend and abduct both arms. However, if the baby has a clavicle fracture, the affected arm might remain at the side, showing restricted movement or inability to fully extend.<\/p>\n\n\n\n In this scenario, the notes mention that the left arm remains at the side during the Moro reflex. This finding is significant because it indicates that there could be a problem with the left arm, which aligns with a clavicle fracture. The newborn\u2019s shallow and irregular respirations, as well as acrocyanosis, are common in newborns and generally resolve as the infant adapts to extrauterine life. The presence of a caput succedaneum and molding of the skull suggests that the baby experienced some degree of trauma during delivery, which is consistent with a clavicle fracture but not necessarily indicative of more severe conditions like a subgaleal hemorrhage or a congenital cardiac defect.<\/p>\n\n\n\n A subgaleal hemorrhage<\/strong> would present with more severe symptoms such as a bulging or tense scalp, which are not noted here. Neonatal abstinence syndrome (NAS)<\/strong> would involve withdrawal symptoms rather than specific arm movement issues, and developmental dysplasia of the hip (DDH)<\/strong> would show asymmetry in the gluteal folds or limited hip movement, not isolated arm findings.<\/p>\n\n\n\n In conclusion, the described symptoms and findings are most consistent with a clavicle fracture.<\/p>\n","protected":false},"excerpt":{"rendered":" A nurse is caring for a newborn who is 4 hr old. Nurses’ Notes Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.Newborn’s respirations are shallow and irregular. Newborn’s skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-135872","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/135872","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=135872"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/135872\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=135872"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=135872"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=135872"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Explanation:<\/h3>\n\n\n\n