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 C
Explanation
A. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.
B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.
C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care
activities.
D. Advise the client to leave the television in the room on when trying to fall asleep - Screen
time before bed can interfere with falling asleep due to the stimulating effect of light and content.
Correct Answer is B
Explanation
A. A flexible activity schedule may increase overstimulation; structured activities with set limits are more appropriate for clients in acute mania.
B. Clients experiencing acute mania often have increased energy expenditure and may neglect meals; providing high-calorie nutritional supplements helps prevent weight loss and maintains adequate nutrition.
C. Eating alone may increase the risk of inadequate intake due to distraction or hyperactivity; supervised or structured meal times are safer.
D. Allowing unrestricted choice of clothing may lead to inappropriate or disorganized attire; guidance is needed to maintain safety and appropriate appearance.
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