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. Inserting an indwelling catheter is within the scope of practice for an LPN and requires technical skill and training that an LPN possesses. This task is appropriate for delegation because it does not require the RN's direct clinical judgment or assessment at the time of insertion. The LPN can perform this procedure based on a specific directive from the RN.
B. Obtaining the abdominal girth is a task that involves assessment and this cannot be delegated by the RN to an LPN.

C. Assessing and documenting the level of consciousness involves critical thinking and

interpretation of assessment findings, making it more appropriate for the registered nurse to perform.

D. Measuring gastric drainage is a task that the LPN can perform, but it is less critical compared to the insertion of an indwelling catheter in this scenario. The RN should prioritize delegating tasks to the LPN that require their specific skills, such as catheter insertion, while reserving simpler tasks for the AP.

A. Explain to the client the consequences of refusal. B. Identify the reason for the client's refusal. C. Document the client's refusal in the medical record. D. Inform the provider of the client's refusal.

Correct Answer is B

Explanation

A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.

B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.

C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.

D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.

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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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Correct Answer is A

Explanation

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Explanation

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