A nurse is assessing a full-term newborn upon admission to the nursery. What clinical findings should the nurse report?
Rust-stained urine
Subconjunctival hemorrhage
Single palmar creases
Transient circumoral cyanosis .
The Correct Answer is C
Choice A rationale
Rust-stained urine is not a normal finding in a full-term newborn and should be reported to the provider. However, it is not typically assessed upon admission to the nursery.
Choice B rationale
Subconjunctival hemorrhage, or a small red or pink spot on the white of the eye, can occur due to the pressure changes during the birth process. It is a harmless condition that does not affect the baby’s vision and does not require treatment.
Choice C rationale
Single palmar creases, also known as “simian lines,” can be a normal variation in hand creases. However, they are also associated with certain genetic conditions, such as Down syndrome, and should be reported to the provider.
Choice D rationale
Transient circumoral cyanosis, or bluish color around the mouth, can be a normal finding in newborns when they are cold or after crying. However, if it persists, it could indicate a problem with the baby’s heart or lungs and should be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying a moist, warm compress to the perineum is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum.
Choice B rationale
Administering methylergonovine 0.2 mg IM is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Methylergonovine is a medication used to prevent or control bleeding of the uterus following childbirth or abortion.
Choice C rationale
Providing the client with a cool sitz bath is the correct action. A sitz bath can help to soothe the perineal area, reduce inflammation, and promote healing.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not the recommended care for a client with a fourth-degree laceration of the perineum 12 hr postpartum. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Vacuum-assisted delivery can increase the risk of postpartum hemorrhage. This is because the use of vacuum can cause trauma to the birth canal and uterus, leading to increased bleeding.
Choice B rationale
A newborn weight of 2.948 kg (6 lb 8 oz) is within the normal range and does not increase the risk of postpartum hemorrhage.
Choice C rationale
Labor induction with oxytocin can increase the risk of postpartum hemorrhage. Oxytocin can cause the uterus to contract too strongly or too frequently, leading to uterine atony (a condition where the uterus fails to contract after delivery), which can result in heavy bleeding.
Choice D rationale
A history of uterine atony places the patient at risk for postpartum hemorrhage. Uterine atony is a condition in which the uterus fails to contract after the delivery of the baby and the placenta, leading to heavy bleeding.
Choice E rationale
A history of human papillomavirus (HPV) does not increase the risk of postpartum hemorrhage. HPV is a sexually transmitted infection that can cause genital warts and cervical cancer, but it does not affect the uterus’s ability to contract after delivery.
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