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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Determining the client's apical pulse rate is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
B. Asking the client if they are taking the medication as prescribed is a direct way to evaluate medication adherence. Open communication with the client can provide valuable insight into their medication-taking behavior.
C. Assessing the client's kidney function is important for monitoring the effects of digoxin therapy but does not directly assess medication adherence.
D. Checking the client's serum medication level can provide information about medication concentration but may not necessarily indicate adherence, as the level could be within the therapeutic range even if the client is not taking the medication as prescribed.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"C"}}
Explanation
Platelet count 90,000/mm3: Sign of Potential Worsening Condition - A decreased platelet count may indicate worsening preeclampsia and a risk of developing HELLP syndrome or thrombocytopenia.
Hematuria: Sign of Potential Worsening Condition - Hematuria suggests potential kidney involvement, which is a serious complication of preeclampsia, indicating a worsening condition. Positive clonus: Sign of Potential Worsening Condition - Positive clonus is a neurological sign associated with preeclampsia and indicates hyperreflexia, which can lead to seizures if untreated. Proteinuria 2+: Sign of Potential Worsening Condition - Increased proteinuria indicates ongoing kidney dysfunction, which is a worsening sign of preeclampsia.
Leukorrhea: Sign of Potential Improvement - Leukorrhea, an increase in vaginal discharge, may indicate a reduction in cervical mucus plug, which is a normal finding in late pregnancy.
BUN 40 mg/dL: Sign of Potential Worsening Condition - Elevated blood urea nitrogen (BUN) levels indicate impaired kidney function, which is a worsening sign of preeclampsia and can lead to complications such as acute kidney injury.
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