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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?

A.

Rust-stained urine.

B.

Subconjunctival hemorrhage.

C.

Single palmar creases.

D.

Transient circumoral cyanosis.

Answer and Explanation

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.


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Related Questions

Correct Answer is ["1227"]

Explanation

Naegele’s rule is a method for estimating the due date of a baby based on the woman’s last menstrual period (LMP).

It involves adding seven days and subtracting three months from the first day of the LMP.

It assumes a 28-day menstrual cycle and a 280-day gestation period, which may vary for different women 1.

Using this rule, if the client’s last menstrual period was March 20, then adding seven days would give March 27.

Subtracting three months would give December 27 of the previous year.

Adding one year would give December 27 of the current year, which is the estimated date of delivery in MMDD format: 1227.

Correct Answer is B

Explanation

The correct answer is. Administering broad-spectrum antibiotics.

Cleansing the site with povidone-iodine is not recommended because it can be irritating and potentially harmful to the exposed neural tissue.

Monitoring the rectal temperature every 4 hours is not appropriate as it can increase the risk of infection and trauma to the site. Axillary temperature monitoring is preferred.

Preparing for surgical closure after 72 hours is incorrect. Surgical closure is typically performed within the first 24 to 48 hours to prevent infection and further damage to the neural tissue.

Administering broad-spectrum antibiotics is crucial to prevent infection, especially since the cerebrospinal fluid is leaking, which increases the risk of meningitis and other infections.

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