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 ["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
When a client is receiving magnesium sulfate by continuous IV infusion for preterm labor, it is important for the nurse to review the serum medication level to ensure that the client is receiving an appropriate dose and to monitor for signs of magnesium toxicity.
Choice A is not an answer because an indirect Coombs test is used to detect antibodies against red blood cells and is not relevant to magnesium sulfate therapy.
Choice C is not an answer because liver enzymes are not directly relevant to magnesium sulfate therapy.
Choice D is not an answer because uric acid levels are not directly relevant to magnesium sulfate therapy.
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