A large for date, term baby is born by assisted delivery. The baby has a lack of spontaneous movement, and weak deep tendon reflexes. There is an absent response to the pain stimuli in the lower limbs. Which of the following conditions causes these manifestations in the newborn?

1. A

   Phrenic nerve injury

2. B

   Cephalhaematoma

3. C

   Spinal cord injury

4. D

   Facial nerve injury

Appeared in: UP NHM CHO 7 Sept 2022(shift-1st)

Explanation

• The newborn's symptoms—lack of spontaneous movement (flaccid paralysis), weak deep tendon reflexes (areflexia), and absent pain response in the lower limbs—form a classic triad for spinal cord injury.
• This type of injury is a known complication of difficult or assisted births, particularly with large infants, where excessive traction or rotation can damage the delicate spinal cord.
• The location of the symptoms (lower limbs) points directly to an injury along the spine that has disrupted motor and sensory pathways below the level of the lesion.

Why Other Options Were Wrong

• Option A: Phrenic nerve injury involves damage to the nerves (C3-C5) that control the diaphragm. This would primarily cause respiratory distress, such as labored breathing and cyanosis, not paralysis and sensory loss in the lower limbs.
• Option B: A cephalhematoma is a collection of blood under the periosteum of a skull bone. It is a localized head injury that does not cross suture lines and does not cause neurological deficits like paralysis or sensory loss in the extremities.
• Option D: Facial nerve injury affects the 7th cranial nerve, leading to paralysis of the facial muscles. This would manifest as an asymmetric crying face, a drooping corner of the mouth, and an inability to close the eye on the affected side, not deficits in the lower limbs.

Related Visual

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Recognition of signs and symptoms of neonatal spinal cord injury following birth trauma as background academic context rather than a clinical decision trigger.
• Nurses must conduct thorough neurological assessments on all newborns, especially after a difficult or instrument-assisted delivery, to promptly identify signs of birth trauma.
• A suspected spinal cord injury is a medical emergency. Nursing priorities include immobilizing the spine, maintaining a patent airway, monitoring for respiratory compromise (if the injury is high), and providing supportive care for temperature instability and autonomic dysfunction.
• Management is multidisciplinary, involving neonatologists, neurologists, and rehabilitation specialists to optimize outcomes and support the family through a devastating diagnosis.

How to Approach the Question

• First, analyze the patient's profile and delivery history: a 'large for date' baby born via 'assisted delivery'. These are significant risk factors for birth trauma.
• Next, systematically list the clinical findings: 1) lack of spontaneous movement, 2) weak deep tendon reflexes, and 3) absent pain response in the lower limbs.
• Synthesize these findings. The combination of motor paralysis, areflexia, and sensory loss points to a severe neurological injury.
• Note the location of the deficits: they are confined to the lower limbs, suggesting an injury to the spinal cord rather than the brain or a peripheral nerve in the upper body.
• Evaluate each option against this clinical picture. Phrenic nerve injury affects breathing. Cephalhematoma is a head lump. Facial nerve injury affects the face.
• Conclude that only a spinal cord injury can explain the specific combination of paralysis and sensory loss in the lower extremities.

Concept Tested & Keywords

• Concept Tested: Recognition of signs and symptoms of neonatal spinal cord injury following birth trauma.
• Stem keywords: large for date, assisted delivery, lack of spontaneous movement, weak deep tendon reflexes, absent response to pain stimuli, lower limbs, newborn
• Lead-in keywords: Which of the following conditions
• Clinical cues: The combination of a large baby and an assisted delivery points to a high risk for birth trauma.
• Clinical cues: The neurological deficits are specifically localized to the lower limbs, suggesting an injury to the spinal cord rather than a cranial nerve or localized head trauma.

Question ID

QbYE7ieg4yA2EF_5Qo1OkI

Copy ID

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 1077-1079

E6 Text Book Of Pediatric Nursing 3rd Panchali Pal — Part 2 (pp 239-476 of 713) p. 13-15

E6 Obstetrics Williams p. 19-36