A nurse is assessing a 2-week-old newborn. Which of the following findings should the nurse report to the provider?
Irregular bluish pigmentation on the sacral area
Slow, rhythmic movements of the lower extremities
Anterior fontanel 3 cm (1.2 in)
Enlarged breasts
The Correct Answer is A
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A gluten-free diet is essential for managing celiac disease, as gluten can trigger harmful immune responses in affected individuals. This diet excludes all forms of wheat, barley, rye, and oats unless they are labeled gluten-free.
Choice B reason: A high-fiber diet is generally healthy but is not specifically related to the management of celiac disease. During exacerbations, it is more important to ensure that all foods are gluten-free to avoid triggering symptoms.
Choice C reason: There is no need for a low-protein diet in celiac disease management. Protein is not related to the immune response triggered by gluten.
Choice D reason: Wheat flour contains gluten and must be avoided in a gluten-free diet. Alternative flours such as rice, corn, or gluten-free blends should be used instead.
Correct Answer is A
Explanation
Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.
Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.
Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.
Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.
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