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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, administer broad-spectrum antibiotics.
Choice A rationale:
Administering broad-spectrum antibiotics is crucial for a newborn with a myelomeningocele that is leaking cerebrospinal fluid to prevent infection. The leaking of cerebrospinal fluid can increase the risk of meningitis, which is an infection of the membranes covering the brain and spinal cord. Broad-spectrum antibiotics are used as a prophylactic measure to reduce this risk.
Choice B rationale:
Monitoring the rectal temperature every 4 hours is important for detecting fever, which could indicate infection. However, it is not the most immediate action required for a newborn with a leaking myelomeningocele. The priority is to prevent infection through the administration of antibiotics.
Choice C rationale:
Cleansing the site with povidone-iodine is not recommended for a myelomeningocele because it can be toxic to the exposed neural tissue. Instead, the area should be covered with a sterile saline dressing to protect the site and prevent drying and further damage to the neural tissue.
Choice D rationale:
While surgical closure is necessary for a newborn with myelomeningocele, it is typically performed within 24 to 48 hours after birth, not after 72 hours. Early closure is essential to reduce the risk of infection and further damage to the exposed spinal cord and nerves.
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. An indirect Coombs' test is not used to determine the risk of hypoglycemia in a baby after birth. It is used to detect antibodies against red blood cells, particularly in the context of blood incompatibility between a pregnant woman and her fetus.
Choice B rationale:
This statement is incorrect. An indirect Coombs' test is not related to determining the amount of amniotic fluid around the fetus. It is used primarily to assess for Rh incompatibility between the mother and fetus.
Choice C rationale:
This statement is incorrect. The test described here is a Doppler ultrasound, not an indirect Coombs' test. Doppler ultrasound is used to study blood flow in the fetus and placenta using ultrasound waves.
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