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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Related Questions
Correct Answer is C
Explanation
Group B Streptococcus β-hemolytic (GBS) is a type of bacteria that can cause serious infections in newborns, such as sepsis, pneumonia, and meningitis. GBS can be transmitted from the mother to the baby during labor and delivery if the mother is colonized with GBS in her vagina or rectum¹.
To prevent GBS infection in newborns, pregnant women who test positive for GBS or have risk factors for GBS should receive intravenous (IV) antibiotics during labor. The antibiotics can reduce the amount of GBS bacteria in the mother's body and lower the chance of passing them to the baby¹².
The recommended antibiotic for GBS prophylaxis is penicillin, which is safe and effective for most women. However, some women may be allergic to penicillin and need an alternative antibiotic. Ampicillin is one of the alternative antibiotics that can be used for GBS prophylaxis in women who have a mild allergy to penicillin (such as rash or itching). Ampicillin is also a type of penicillin, but it has a slightly different structure and may not cause an allergic reaction in some people²³.
Therefore, the nurse should plan to administer ampicillin to the client who tested positive for GBS and has a mild allergy to penicillin. The nurse should also monitor the client for any signs of anaphylaxis (a severe allergic reaction) and have epinephrine ready in case of emergency²³.
The other options are not medications that the nurse should administer to the client:
- a) Cefotetan is another alternative antibiotic that can be used for GBS prophylaxis in women who have a severe allergy to penicillin (such as anaphylaxis or angioedema). However, it is not indicated for women who have a mild allergy to penicillin, as it may still cause cross-reactivity and an allergic reaction²³.
- b) Fluconazole is an antifungal medication that is used to treat fungal infections, such as candidiasis (thrush) or cryptococcal meningitis. It is not effective against bacterial infections, such as GBS, and it is not indicated for GBS prophylaxis⁴.
- d) Doxycycline is an antibiotic that is used to treat bacterial infections, such as chlamydia, gonorrhea, or Lyme disease. It is not effective against GBS and it is not indicated for GBS prophylaxis. Moreover, doxycycline is contraindicated in pregnancy, as it can cause harm to the fetus, such as tooth discoloration or bone growth problems.
Correct Answer is B
Explanation
When providing postpartum care teaching to a client, the nurse should include accurate and appropriate information. Option b) "You can expect your breasts to be firm and tender 3 to 5 days after delivery" is a correct statement.
Breast engorgement is a common occurrence around the third to fifth day after delivery as the breasts transition from producing colostrum to mature milk. This can cause the breasts to become firm, swollen, and tender. It is important for the client to be aware of this normal physiological change and to understand how to manage it effectively, such as by applying warm or cold compresses, expressing milk, and ensuring proper breastfeeding techniques.
Option a) "Your bleeding will remain bright red for the next 6 to 8 weeks" is an incorrect statement. After childbirth, the bleeding, called lochia, typically progresses from bright red to a pinkish color and then to a yellowish-white discharge. The duration and characteristics of lochia can vary for each individual, but it generally resolves within a few weeks.
Option c) "You don't need to use birth control if you are exclusively breastfeeding" is an incorrect statement. While breastfeeding can provide some natural contraception, it is not foolproof, and the client can still ovulate and become pregnant. It is important for the client to discuss and choose a suitable method of contraception with her healthcare provider.
Option d) "You should begin performing Kegel exercises 6 to 7 weeks after delivery" is an incorrect statement. Kegel exercises, which strengthen the pelvic floor muscles, can be started as early as the immediate postpartum period and are beneficial for promoting bladder and bowel control, as well as aiding in postpartum recovery. The client can begin performing Kegel exercises soon after delivery, as guided by her healthcare provider.
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