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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

Answer and Explanation

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

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Correct Answer is A

Explanation

Rationale

Pyloric stenosis is a condition characterized by narrowing of the pylorus, the opening between the stomach and the small intestine. This narrowing obstructs the passage of food from the stomach to the intestines. This leads to typical projectile postprandial vomiting.

B, C, D are not typical features of pyloric stenosis

A. "Preterm newborns have a smaller body surface area than normal newborns." B. "Preterm newborns lack adequate temperature control mechanisms." C. "The heat in the incubator rapidly dries the sweat of preterm newborns." D. "The added brown fat layer in a preterm newborn reduces his ability to generate heat.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?

Correct Answer is A

Explanation

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?