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.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: For individuals who are lactose intolerant, it is important to find alternative sources of calcium. Non-dairy sources such as fortified plant-based milks, leafy greens, and calcium-fortified foods can provide the necessary calcium without causing discomfort.
Choice B reason: Flavored yogurt often contains added sugars and may still have lactose, which can cause symptoms in those who are lactose intolerant. It's better to choose lactose-free options or plant-based alternatives.
Choice C reason: Lactose intolerance means that the body cannot effectively digest lactose found in milk, regardless of whether it is plain or chocolate. Therefore, it is not advisable to consume any milk that contains lactose.
Choice D reason: Drinking milk on an empty stomach can actually worsen symptoms for someone who is lactose intolerant. It is better to avoid milk or choose lactose-free alternatives.
Correct Answer is A
Explanation
Choice A reason: Slurred speech may indicate a stroke or other neurological complication, which is a medical emergency. Sickle cell anemia can lead to such complications, and immediate assessment is crucial.
Choice B reason: While a partial-thickness burn requires care, it is not as immediately life-threatening as potential neurological complications. The toddler should be assessed after more urgent cases.
Choice C reason: A pain level of 7 is significant, but pain management can be addressed after more critical needs are met. The adolescent's pain should be managed effectively once urgent cases are stabilized.
Choice D reason: Administering an IV bolus of nafcillin for osteomyelitis is important, but it does not take precedence over potential neurological issues. The toddler should receive the medication promptly after urgent assessments.
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