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).
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"He is just cold”. is not the correct choice. While newborns can have cold hands and feet due to their immature thermoregulation, it would not explain persistent blue hands.
Choice B rationale:
"He may have been born with a heart problem”. is not the correct choice as it suggests a congenital heart defect. While cyanosis (bluish discoloration) can be associated with some heart problems, the hands alone being blue is less likely to be solely related to a heart issue.
Choice C rationale:
"The hands are always blue in a newborn”. is not the correct choice. While newborns may have bluish extremities (acrocyanosis) during the first few days after birth due to their developing circulatory system, persistent blue hands beyond this period would require further assessment.
Choice D rationale:
The correct choice is that "The circulation in his hands is not fully developed.”. Newborns have a developing circulatory system, and sometimes, their peripheral circulation takes some time to mature, leading to transient blue hands. However, if the blue color persists or worsens, it's essential to evaluate for any underlying issues.
Correct Answer is ["B","C","D"]
Explanation
Choice A: Warm the bottle in the microwave.
- Rationale: Warming bottles in the microwave is not recommended. Microwaving can cause uneven heating, creating hot spots in the milk or formula that can burn the baby's mouth. Instead, bottles should be warmed by placing them in a container of warm water or using a bottle warmer.
Choice B: Store prepared bottles in the refrigerator.
- Correct
- Rationale: Prepared bottles of formula should be stored in the refrigerator to prevent bacterial growth. Formula should be used within 24 hours of preparation when properly stored in the refrigerator.
Choice C: Discard unused formula in used bottle after 2 hours.
- Correct
- Rationale: Any unused formula that has been in contact with the baby’s mouth should be discarded after 2 hours due to the risk of bacterial contamination. Bacteria from the baby's saliva can grow in the leftover formula.
Choice D: Never prop a bottle.
- Correct
- Rationale: Bottles should never be propped up and left in the baby’s mouth. This practice increases the risk of choking, ear infections, and tooth decay. Caregivers should always hold the bottle and the baby during feedings.
Choice E: Formula is available in three forms.
- Correct
- Rationale: Formula is available in three forms: powdered, concentrated liquid, and ready-to-feed. Parents should be informed of these options so they can choose the most convenient or appropriate form based on their needs.
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