A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hours old. The nurse should plan to notify the provider of which of the following findings?
Head circumference 1 cm greater than chest
Positive Babinski reflex on bilateral feet
Passage of meconium stool
Pinna below the outer canthus of the eye
The Correct Answer is D
A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.
B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.
C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.
D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dependent edema may occur in some cases of pericarditis but is not typically a priority finding compared to chest pain, which can indicate cardiac compromise.
B. A pericardial friction rub is a classic finding in pericarditis but is not necessarily the priority over the chest pain, which requires immediate attention.
C. A paradoxical pulse (pulse amplitude decreasing during inspiration) can occur in pericarditis but is not typically as concerning as substernal chest pain.
D. Substernal chest pain is a common and significant symptom of pericarditis, and assessing and managing the pain is a priority to ensure adequate cardiac function and alleviate discomfort.
Correct Answer is B
Explanation
A. Apply oxygen at 3 L/min per nasal cannula: While oxygenation is important, there is no
indication in the scenario that the client requires oxygen supplementation at this time. Checking oxygen saturation would be more relevant if there were respiratory concerns.
B. Review the chest x-ray report: This is the most appropriate action before initiating the IV
infusion to ensure proper placement of the central venous catheter and absence of complications such as pneumothorax or malposition.
C. Flush the catheter with sterile water: Flushing the catheter with sterile water is not necessary before starting the infusion, especially without confirming proper catheter placement through chest x-ray.
D. Obtain a peripheral blood glucose level: While monitoring blood glucose levels may be
important in certain clinical situations, it is not directly relevant to initiating an IV infusion of Ringer's lactate via a central venous catheter.
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