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 D
Explanation
The correct answer is choice d. Transmission can occur via the saliva and urine of the newborn.
Choice A rationale:
Lesions are not typically visible on the mother’s genitalia with cytomegalovirus (CMV) infection. CMV is often asymptomatic or presents with nonspecific symptoms, and visible lesions are not a characteristic feature.
Choice B rationale:
CMV does not require airborne precautions. It is primarily transmitted through direct contact with bodily fluids such as saliva, urine, blood, and breast milk.
Choice C rationale:
Prophylactic treatment with acyclovir is not standard for CMV. Acyclovir is used for herpes simplex virus infections, not CMV.
Choice D rationale:
CMV can indeed be transmitted via the saliva and urine of the newborn. This is a common mode of transmission, especially in settings like daycare centers where young children are in close contact.
Correct Answer is A
Explanation
Choice A rationale
It is crucial to confirm that informed consent has been obtained before administering a dinoprostone insert to induce labor. This is because the patient has the right to understand the benefits, risks, and alternatives of the procedure before it is performed.
Choice B rationale
Positioning the client in a semi-Fowler’s position for 1 hour after administration is not necessary. After the dinoprostone insert is placed, the patient should remain lying down for at least 30 minutes. After this, the patient may sit up or walk, being careful to ensure the insert remains in place.
Choice C rationale
Allowing the medication to reach room temperature before administration is not a requirement for dinoprostone insert. The medication can be administered as soon as it is needed.
Choice D rationale
Advising the client to avoid urinating until after administration is not necessary. The patient can urinate as needed after the dinoprostone insert is placed.
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