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: Hemoglobin (Hgb) of 12 g/dL is within the normal range for school-age children and is not specifically indicative of nephrotic syndrome.
Choice B reason: A serum protein level of 4.2 g/dL is lower than the normal range, which is typically between 6 and 8 g/dL. This finding is consistent with nephrotic syndrome, as the condition is characterized by proteinuria and hypoalbuminemia, leading to low serum protein levels.
Choice C reason: A BUN (Blood Urea Nitrogen) level of 15 mg/dL is within the normal range for children and does not specifically indicate nephrotic syndrome. Nephrotic syndrome is characterized by protein loss, not necessarily changes in BUN levels.
Choice D reason: A serum sodium level of 144 mEq/L is within the normal range for children. While electrolyte imbalances can occur in nephrotic syndrome, this value does not specifically indicate the condition.
Correct Answer is D
Explanation
Choice A reason: Contact precautions are used for infections that spread by direct or indirect contact with the patient or the patient's environment. While important, they are not the primary precaution for pertussis.
Choice B reason: Airborne precautions are used for diseases that are transmitted through the air over long distances, such as tuberculosis. Pertussis does not typically require airborne precautions.
Choice C reason: Protective precautions are used to protect immunocompromised patients from being infected by others. This is not applicable for a child with pertussis, who is the source of infection.
Choice D reason: Droplet precautions are used for diseases that are transmitted through large droplets expelled during coughing, sneezing, or talking. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets, making droplet precautions the appropriate choice.
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