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16. 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 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.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
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
16. 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 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.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
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
The Correct Answer is ["Moro reflex color of extremities head assessment maternal urine toxicology screen gluteal folds"]
Subgaleal hemorrhage is a rare but potentially serious condition in newborns characterized by bleeding beneath the scalp's galea aponeurotica, a fibrous tissue layer between the scalp and the skull.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Preterm newborns have immature physiological mechanisms to regulate their body temperature effectively which include subcutaneous fat deposition, fully developed sweat glands, and the ability to shiver. They also have a large surface area increasing heat loss. As a result, preterm
infants are at a higher risk of hypothermia. Incubator care assist in the control of body temperature in the premature neonates.
Correct Answer is D
Explanation
A pink rash appearing on the newborn's trunk while receiving phototherapy may indicate a potential adverse reaction to the treatment, such as a phototoxic reaction or erythema. This finding should be promptly assessed by the nurse as it may indicate skin irritation or sensitivity to the phototherapy.
A. The mother applying lotion to the newborn's skin is generally not contraindicated during phototherapy,
B. Covering the newborn's eyes with a mask is a standard practice during phototherapy to protect the eyes from exposure to the light, and it does not typically require intervention.
C. An increase in the number of newborn's stools is a common side effect of phototherapy and is not typically concerning unless accompanied by other symptoms such as diarrhea or dehydration.
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