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 B
Explanation
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
Correct Answer is A
Explanation
Choice A reason: Keeping electrical wires hidden from view is essential to prevent toddlers from pulling on them, which can lead to electrical burns or other injuries. It is a proactive measure to ensure a safe environment for children who are naturally curious and prone to exploring with their hands.
Choice B reason: Turning pot handles toward the front of the stove is dangerous as it increases the risk of toddlers reaching up and pulling hot contents onto themselves. The correct practice is to turn pot handles toward the back of the stove to keep them out of reach of children.
Choice C reason: Encouraging outdoor activities between the hours of 11:00 and 13:00 can expose toddlers to the sun's peak intensity, increasing the risk of sunburn. It is safer to encourage outdoor activities outside these hours when the sun is less intense.
Choice D reason: Setting the water heater to 60°C (140°F) is too high and poses a scalding risk. The recommended temperature to prevent burns is 49°C (120°F), which is hot enough for household use but not so hot as to cause immediate burns upon contact.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.