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 A
Explanation
Choice A rationale
Breast tenderness is a common side effect of clomiphene citrate. This medication stimulates the release of hormones needed for ovulation, which can also cause changes in breast tissue leading to tenderness.
Choice B rationale
Urinary frequency is not a known side effect of clomiphene citrate. However, urinary frequency can be a symptom of pregnancy, which is the intended outcome of using this medication.
Choice C rationale
Chills are not a known side effect of clomiphene citrate. If a patient experiences chills while taking this medication, it may be due to other causes and should be evaluated by a healthcare provider.
Choice D rationale
Tinnitus, or ringing in the ears, is not a known side effect of clomiphene citrate. If a patient experiences tinnitus while taking this medication, it may be due to other causes and should be evaluated by a healthcare provider.
Correct Answer is D
Explanation
Choice A rationale
Fresh citrus fruits are a good source of vitamin C, but they do not contain vitamin B125. Vitamin B12 is not naturally present in plant foods, so vegans need to get it from fortified foods or supplements.
Choice B rationale
Raw carrots are a good source of vitamins A and K, and dietary fiber, but they do not contain vitamin B125. Vegans need to get vitamin B12 from other sources.
Choice C rationale
Brown rice is a good source of B vitamins like B1 (thiamin) and B3 (niacin), but it does not contain vitamin B125. Vegans need to get vitamin B12 from other sources.
Choice D rationale
Fortified soy milk is a good source of vitamin B12 for vegans. Many brands of soy milk are fortified with vitamins, including B12, making them a good choice for vegans looking to increase their vitamin B12 intake.
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