A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?

A newborn who is 8 hr old and has acrocyanosis.

A newborn who is 18 hr old and has not voided.

A newborn who is 24 hr old and has not passed meconium.

A newborn who is 12 hr old and has an axillary temperature of 37.8°C (100° F).

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.

Choice B rationale:

A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.

Choice C rationale:

A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.

Choice D rationale:

The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.

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Correct Answer is B

Explanation

Choice A rationale:

A white blood cell count of 15,000 does not necessarily indicate a severe infection. In newborns, WBC counts are typically higher than in adults, and they gradually decrease over the first few days after birth. A value of 15,000 falls within the normal range for a newborn and is not indicative of a severe infection.

Choice B rationale:

A white blood cell count of 15,000 is considered a normal range for a newborn. Newborns have higher WBC counts as a natural response to the stress of birth and exposure to the outside environment. The immune system is still developing, and elevated WBC counts are normal during this period.

Choice C rationale:

Assuming there are no other indications of lab error, such as abnormal results in other tests, it would be premature to label the WBC count as a lab error. Additionally, healthcare professionals should always consider the overall clinical picture before assuming a lab error based on a single result.

Choice D rationale:

There is no immediate need to call the doctor based solely on the WBC count of 15,000. Medical decisions should be made in the context of the newborn's overall clinical condition, and a single lab result does not warrant an immediate call to the doctor.

A. Cephalhematoma. B. Nevus flammeus. C. Caput succedaneum. D. Molding.

Correct Answer is A

Explanation

Choice A rationale:

Cephalhematoma is the correct answer because it presents as a swelling on the newborn's head confined to one cranial bone and does not cross suture lines. It usually resolves on its own within a few weeks to months but can increase the risk of jaundice due to the breakdown of red blood cells in the hematoma.

Choice B rationale:

Nevus flammeus, also known as a port-wine stain, is a type of vascular birthmark. It presents as a flat, pink, or red mark on the skin and does not involve swelling of the head. This choice is unrelated to the findings described in the question and is therefore incorrect.

Choice C rationale:

Caput succedaneum refers to a diffuse, soft tissue swelling of the scalp that does cross suture lines. It is caused by pressure on the head during delivery, leading to edema and bruising. It typically resolves within a few days after birth.

Choice D rationale:

Molding refers to the shaping of the fetal head during childbirth as it passes through the birth canal. It may cause temporary elongation or molding of the head, but it does not present as a localized swollen area. This choice is not applicable to the findings mentioned in the question and is thus incorrect.

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A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a newborn's white blood cell count (WBC) is 15,000. The nurse is aware that:.

Correct Answer is B

Explanation

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following?

Correct Answer is A

Explanation

A nurse is collecting data from a newborn who is 12 hours old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is postpartum about bathing her newborn. Which of the following statements by the client indicates a need for further teaching?

In a newborn infant, which of the following is the liver's job related to bilirubin?

The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?

The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?

A newborn is most interested in eating in which wake and sleep state?

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).