A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
Rust-stained urine.
Single palmar creases.
Subconjunctival hemorrhage.
Transient circumoral cyanosis.
The Correct Answer is B
The correct answer is choice B. Single palmar creases.
Choice A rationale:
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
Choice B rationale:
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
Choice C rationale:
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
Choice D rationale:
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”
Choice A rationale:
The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.
Choice B rationale:
An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.
Choice C rationale:
Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.
Choice D rationale:
Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.
Correct Answer is A
Explanation
Choice A rationale:
When a newborn is receiving phototherapy for hyperbilirubinemia, it is essential to avoid using lotions or ointments on the skin. Phototherapy works by breaking down bilirubin in the skin, and any barriers like lotions or ointments can interfere with this process. The baby's skin needs to be exposed to the light to effectively reduce bilirubin levels.
Choice B rationale:
Dressing the newborn in lightweight clothing is a correct action during phototherapy. The baby should be undressed and placed under the phototherapy lights, with only a diaper on to maximize skin exposure to the light.
Choice C rationale:
Keeping the newborn supine throughout treatment is not a recommended action during phototherapy. To optimize skin exposure to the light, the baby should be placed in a prone position, with the back exposed to the light source.
Choice D rationale:
Measuring the newborn's temperature every 6 hours is essential, but it is not directly related to phototherapy. Temperature monitoring is a routine part of newborn care to assess for signs of infection or other health issues.
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