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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needle-stick injuries. Needles should be disposed of as one unit to minimize the risk of injury.
B. Broken glass should be disposed of in a puncture-proof container to prevent injuries. Placing it directly in a wastebasket increases the risk of puncture injuries to individuals handling the waste.
C. Recapping needles increases the risk of needle-stick injuries. Needles should not be recapped after use unless there is no safer alternative. Instead, they should be disposed of as one unit.
D. Lancets, needles, and other sharp objects should be placed in puncture-proof containers immediately after use to prevent injuries. This practice helps ensure the safety of healthcare workers and others who handle waste.
Correct Answer is C
Explanation
A. Set up the sterile field 7.6 cm (3 in) below waist level - While it's important to maintain a sterile field, the specific height mentioned is not a standard requirement.
B. Hold the bottle of sterile solution with the palm over the label while pouring - This is
incorrect because it increases the risk of contaminating the solution by touching the label.
C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border - This is the correct action as it ensures that sterile items are easily accessible without reaching over the sterile field, minimizing the risk of contamination.
D. Place the lid of a bottle of sterile solution within the sterile field - Placing the lid inside the sterile field increases the risk of contamination, as the lid is not considered sterile.
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