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 A
Rust-stained urine.
Rust-stained urine in a newborn can be a sign of a serious medical condition and should be reported to the provider.
Choice B is not the answer because subconjunctival hemorrhage in a newborn is usually normal and harmless.
It may be caused by pressure changes during vaginal delivery and will disappear on its own after two or three weeks.
Choice C is not the answer because single palmar creases develop while a baby
is growing in the womb and appear in about 1 out of 30 people.
While some single palmar creases may indicate problems with development and be linked with certain disorders, it is not necessarily a cause for concern.
Choice D is not the answer because transient circumoral cyanosis refers to blue discoloration around the mouth only and is usually seen in infants.
It’s often considered a type of acrocyanosis which happens when small blood vessels shrink in response to cold.
This is very normal in infants during the first few days after birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A nurse caring for a client following a vaginal delivery of a term fetal demise should offer the client the option to bathe and dress their baby if they would like to.
Choice A is incorrect because it is not appropriate for the nurse to suggest that the client should name the baby.
Choice B is incorrect because it is not appropriate for the nurse to suggest that not holding the baby will make letting go much harder.
Choice C is incorrect because it is not appropriate for the nurse to make assumptions about future pregnancies.
Correct Answer is C
Explanation
A nurse caring for a client who has hyperemesis gravidarum should anticipate urine ketones test.
Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that results in dehydration, weight loss, and ketosis.
Urine ketones test is done to check for ketosis which is a sign of starvation 2.
Choice A, Rapid plasma reagin, is not an answer because it is a blood test used to screen for syphilis.
Choice B, Prothrombin time, is not an answer because it is a blood test used to measure how long it takes for blood to clot.
Choice D, Urine culture, is not an answer because it is a test used to detect and identify bacteria or yeast that may be causing a urinary tract infection.
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