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 D
Explanation
A nurse conducting a class for a group of clients about birth control should include information about having an annual examination to assess their diaphragm.
A diaphragm should be replaced at least every 2 years and it’s important to
bring it to an annual checkup so the healthcare provider can check the fit.
Choice A is incorrect because spermicide should be used immediately before sexual intercourse, not 3 hours prior.
Choice B is incorrect because fertility can return immediately after IUD removal.
Choice C is incorrect because emergency contraception is intended for backup contraception only and not as a primary method of birth control
Correct Answer is C
Explanation
A nurse caring for a client who is at 36 weeks of gestation and has methicillin- resistant Staphylococcus aureus (MRSA) should initiate Contact Precautions.
Choice A is incorrect because Droplet Precautions are not necessary for MRSA.
Choice B is incorrect because a Protective Environment is not necessary for MRSA.
Choice D is incorrect because Airborne Precautions are not necessary for MRSA.
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