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 C
Explanation
Choice A reason: Using a bulb syringe to suction the nares is a common practice for clearing nasal passages in infants, but it is not the primary concern for an infant with a tracheostomy, which requires specific care to maintain airway patency.
Choice B reason: Providing antibiotic therapy may be necessary if there is an infection, but it is not a standard care action for a tracheostomy without evidence of infection.
Choice C reason: Administering intermittent suction via the tracheostomy is essential to clear secretions and maintain airway patency, which is the greatest risk for an infant with a tracheostomy.
Choice D reason: Placing an infant in a prone position to sleep is not recommended due to the increased risk of sudden infant death syndrome (SIDS). Infants should be placed on their backs to sleep.
Correct Answer is C
Explanation
Choice A reason: Hypothermia is not a common finding associated with inhalation of gasoline. It typically occurs due to exposure to cold temperatures and is not related to chemical inhalation.
Choice B reason: Hyperactive reflexes are not typically associated with gasoline inhalation. They can be a sign of neurological disorders or a response to certain medications, but not commonly from inhalants.
Choice C reason: Mydriasis, which is the dilation of the pupils, can occur with inhalation of gasoline due to its effect on the nervous system. It is a sign that the nurse should be aware of during the assessment.
Choice D reason: Pinpoint pupils are more commonly associated with opioid overdose and not with inhalation of gasoline. The nurse should expect to see dilated pupils rather than constricted ones.
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