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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.

B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.

C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.

D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.

A. Speak directly into one of the client's ears. B. Rephrase sentences the client does not understand. C. Drop voice volume at the end of sentences. D. Exaggerate lip movements.

Correct Answer is B

Explanation

A. Speaking directly into one of the client's ears may not effectively improve communication for someone with a hearing impairment, especially if the impairment is bilateral.

B. Rephrasing sentences the client does not understand can help improve comprehension by providing information in a different way.

C. Dropping voice volume at the end of sentences may make it difficult for the client to hear the end of the sentence, especially if they have a hearing impairment.

D. Exaggerating lip movements may not be helpful and can actually make lip-reading more difficult for some individuals.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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