A nurse is assessing a 1-hour-old newborn.Which of the following findings should the nurse report to the provider?
Transient circumoral cyanosis.
Transient strabismus.
Caput succedaneum.
Generalized petechiae.
The Correct Answer is D
Choice A rationale
Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.
Choice B rationale
Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.
Choice C rationale
Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.
Choice D rationale
Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early detection and management of any potential infections.
Choice B rationale
Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage, not for routine use post-amniotomy.
Choice C rationale
Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.
Choice D rationale
Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}
Explanation
Preterm Labor
Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:
- Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
- Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
- Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
- Low backache: The client reports cramping and low back pain.
Preterm Prelabor Rupture of Membranes (PPROM)
PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:
- Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.
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