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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: While exposure to secondhand smoke is unhealthy and should be avoided, it is not commonly listed as a trigger for seizures. The primary concern with secondhand smoke is its impact on respiratory health.

Choice Breason: A prolonged headache can be a symptom of various conditions, but it is not generally considered a direct trigger for seizures. However, if a headache is related to a neurological condition, it may be associated with an increased risk of seizures.

Choice Creason: Decreased temperature, or being cold, is not typically a trigger for seizures. Seizure triggers are usually related to changes in the body's internal environment or external stimuli that affect the nervous system.

Choice D reason: Inadequate sleep is a well-known trigger for seizures. Sleep deprivation can lead to increased seizure activity in individuals with seizure disorders. Ensuring adequate and regular sleep is an important part of managing seizure disorders.

A. Loosen tight clothing around the child's neck. B. Firmly hold the child's arms to one side. C. Place a pillow under the child's head. D. Insert a tongue blade into the child's mouth. E. Clear the area of hard objects.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.

Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.

Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.

Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.

Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.

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A nurse is assessing a 2-week-old newborn. Which of the following findings should the nurse report to the provider?

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