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?

Subconjunctival hemorrhage

Rust-stained urine

Transient circumoral cyanosis

Single palmar creases

Answer and Explanation

The Correct Answer is A

- A: Subconjunctival hemorrhage is generally a benign condition in newborns, often caused by the pressure changes during birth and does not typically require intervention.
- B: Rust-stained urine could indicate urate crystals, which are common in newborns and not usually a concern unless accompanied by other symptoms.
- C: Transient circumoral cyanosis can occur normally in newborns due to immature circulation but should resolve quickly; persistent or severe cases may require further evaluation.
- D: Single palmar creases may be associated with certain genetic conditions and warrant further investigation and reporting to a healthcare provider.

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Correct Answer is B

Explanation

Rationale:

A. Inserting a urinary catheter is an invasive procedure and should not be the first action taken to address bladder distention following a vaginal birth. It should only be considered if the client is unable to void voluntarily.

B. Assisting the client to the bathroom is the initial intervention to attempt to relieve bladder distention. Encouraging the client to void in a comfortable and familiar environment may stimulate urination and help alleviate the distention.

C. Offering the client a sitz bath may provide comfort and promote perineal healing but is not the first intervention for bladder distention.

D. Pouring warm water over the client's perineum may also provide comfort but does not directly address bladder distention.

A. WBC count 11,000/mm3 (5,000 to 10,000/mm3) B. Hematocrit 37% (37% to 47%) C. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL) D. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)

Correct Answer is C

Explanation

Rationale:

A. A WBC count of 11,000/mm3 is slightly elevated but may be within normal limits, as the normal range for WBC count can vary slightly depending on the laboratory. It is not typically concerning during pregnancy.

B. A hematocrit of 37% is within the normal range for pregnancy (37% to 47%) and does not require immediate reporting to the provider.

C. A fasting blood glucose level of 180 mg/dL is significantly elevated and indicates hyperglycemia, which may be indicative of gestational diabetes mellitus or pre-existing diabetes. This finding should be reported to the provider for further evaluation and management.

D. A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL) and does not require immediate reporting to the provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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