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: This statement is developmentally appropriate and helps to alleviate the child's anxiety about pain during the procedure. It uses language that a 4-year-old can understand without causing unnecessary fear.
Choice B reason: While it is comforting to know a parent will be close by, this statement is not accurate as parents are typically not present in the operating room during the procedure. It could lead to confusion and distress when the parent is not there.
Choice C reason: This statement is too vague and may not be fully understood by a child. It lacks the reassurance that the child will not feel pain, which is an important aspect to address.
Choice D reason: Although this statement is positive and forward-looking, it does not address the child's immediate concerns about the procedure itself. It is important to reassure the child about what to expect during the surgery.
Correct Answer is D
Explanation
Choice A reason: Introducing popcorn as a healthy snack at 12 months of age is not recommended due to the risk of choking. Popcorn is a choking hazard for young children and should be avoided until they are older.
Choice B reason: Providing 36 oz of milk per day to a toddler may be excessive and can lead to iron deficiency anemia due to the displacement of other iron-rich foods. The American Academy of Pediatrics recommends 16-24 oz of milk per day for toddlers.
Choice C reason: Offering 8 to 10 oz of juice per day to a preschooler exceeds the American Academy of Pediatrics' recommendation of limiting juice to 4-6 oz per day for children 1-6 years old to prevent dental caries and ensure they consume more whole fruits.
Choice D reason: Encouraging a 15-year-old to increase calcium intake is appropriate as adolescence is a critical period for bone development. Adequate calcium intake supports optimal bone growth and density, helping to prevent osteoporosis later in life.
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.