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 D

A. Subconjunctival hemorrhage is common in newborns due to birth trauma and usually resolves without intervention. It does not typically require reporting.

B. Rust-stained urine in the first few days of life is caused by uric acid crystals and is considered a normal finding during neonatal adaptation.

C. Transient circumoral cyanosis (bluish discoloration around the mouth) can occur immediately after birth due to immature peripheral circulation and generally resolves quickly with warming and oxygenation.

D. A single palmar crease, especially if present on one hand, can be associated with chromosomal abnormalities such as trisomy 21 (Down syndrome). This finding warrants further evaluation and should be reported to the provider for assessment and potential diagnostic follow-up.

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Correct Answer is ["C","G","H"]

Explanation

A. Peripheral edema 2+ bilateral lower extremities - Peripheral edema is common postpartum and does not typically require immediate follow-up unless it is associated with other concerning signs or symptoms.
B. Blood pressure 136/6 mm Hg - The blood pressure provided appears to be incorrect, as the diastolic pressure is unusually low. However, given the options provided, blood pressure is not explicitly mentioned in the scenario as a critical factor requiring immediate follow-up.
C. Lateral deviation of the uterus - Lateral deviation of the uterus suggests uterine atony, a potential complication of postpartum hemorrhage, requiring immediate follow-up and intervention to prevent further complications.
D. Pain rating of 3 on a scale of 0 to 10 - While increased pain should be addressed, it does not necessarily indicate an emergency situation requiring immediate follow-up compared to other findings such as uterine deviation or excessive bleeding.
E. Deep tendon reflexes 1+ - This finding is within normal limits and does not require immediate follow-up.
F. Breasts soft - Soft breasts are expected in the postpartum period and do not typically require immediate follow-up unless associated with other concerning signs or symptoms.

G. Large amount of lochia rubra - A large amount of bright red lochia could indicate postpartum hemorrhage, necessitating immediate follow-up and intervention to prevent further complications.
H. Uterine tone soft - Soft uterine tone suggests uterine atony, which is a potential complication requiring immediate follow-up and intervention to prevent excessive bleeding.

A. A client who is at 36 weeks of gestation and reports back pain following intercourse B. A client who is at 8 weeks of gestation and reports severe vomiting C. A client who is at 10 weeks of gestation and reports frequent urination D. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers

Correct Answer is B

Explanation

Rationale:

A. Back pain following intercourse at 36 weeks of gestation may be common and is not typically indicative of an urgent issue.

B. Severe vomiting in early pregnancy could indicate hyperemesis gravidarum, which may require immediate assessment and intervention to prevent dehydration and electrolyte imbalances.

C. Frequent urination at 10 weeks of gestation is common due to hormonal changes and increased pressure on the bladder from the growing uterus, but it does not typically require immediate assessment unless accompanied by other concerning symptoms.

D. Periodic tingling of the fingers at 24 weeks of gestation could be due to carpal tunnel syndrome, which is common in pregnancy but does not usually require urgent assessment unless severe or accompanied by other symptoms.

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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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