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.
Subconjunctival hemorrhage.
Single palmar creases.
Transient circumoral cyanosis.
The Correct Answer is C
Rationales
A. Rust-stained urine.
Rust or brick-dust staining in the diaper is usually caused by urate crystals in the urine. This is a common and benign finding in newborns during the first days of life, particularly when fluid intake is still low. It does not require provider notification unless it persists beyond the first week or is accompanied by other abnormalities.
B. Subconjunctival hemorrhage.
A subconjunctival hemorrhage often results from pressure during delivery, especially in vaginal births. It appears as a bright red patch on the sclera but is harmless and resolves spontaneously within several weeks. It is considered a normal newborn finding and does not need to be reported.
C. Single palmar creases.
A single transverse palmar crease, also known as a simian crease, can be associated with chromosomal abnormalities such as Down syndrome. While it may sometimes be an isolated normal variant, its presence warrants further evaluation. The nurse should report this finding to the provider for assessment and potential genetic follow-up.
D. Transient circumoral cyanosis.
Brief bluish discoloration around the lips in a newborn is typically due to vasomotor instability and is common when the infant is crying or cold. As long as the central mucous membranes remain pink and oxygenation is normal, this finding is not concerning and usually resolves without intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants
that occurs when the sole of the foot is stroked from heel to toe.
In response to this stimulus, the big toe moves upward or toward the top surface of the foot and the other toes fan out.
Choice A is not an answer because flexion of the forearm is not a response to stimulation of the foot.
Choice B is not an answer because downward curl of the toes is not a response
to stimulation of the foot.
Choice D is not an answer because extension of the leg is not a response to
stimulation of the foot.
Correct Answer is A
Explanation
Thrombocytopenia is defined as a platelet count of less than 150,000/microL1.
Severe neonatal thrombocytopenia (platelet count <50,000/microL) can be associated with bleeding and potentially significant morbidity.
As a result, it is important to identify at-risk neonates and report low platelet counts to the provider.
Choice B is incorrect because a hematocrit of 48% is within the normal range for a newborn.
Choice C is incorrect because a blood glucose level of 58 mg/dl is within the normal range for a newborn.
Choice D is incorrect because a hemoglobin level of 16 g/dL is within the normal range for a newborn.
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