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 A
Explanation
“I should increase my calcium intake while taking this medication.” A client who is receiving medroxyprogesterone IM for contraception should increase their calcium intake while taking this medication .
Medroxyprogesterone can cause loss of bone mineral density which can increase the risk of osteoporosis. Increasing calcium intake can help maintain bone health.
Choice B, “I should discontinue this medication if I experience spotting,” is not an answer because spotting is a common side effect of medroxyprogesterone and does not require discontinuation of the medication.
Choice C, “I will need to return to the clinic in 8 weeks for my next injection,” is not an answer because medroxyprogesterone IM is given every 3 months, not every 8 weeks.
Choice D, “I will get two shots each time I receive this medication,” is not an answer because only one injection is given at a time.
Correct Answer is C
Explanation
“This medication prevents seizures.” Magnesium sulfate is a mineral that is given intravenously to women with preeclampsia to reduce the risk of seizures or eclampsia.
Preeclampsia is a condition of high blood pressure and protein in the urine during pregnancy.
Choice A is incorrect because magnesium sulfate does not stabilize the fetal heart rate.
Choice B is incorrect because magnesium sulfate does not improve tissue perfusion.
Choice D is incorrect because magnesium sulfate does not increase cardiac output.
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