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?
Single palmar creases.
Rust-stained urine.
Transient circumoral cyanosis.
Subconjunctival hemorrhage.
The Correct Answer is A
The correct answer is choice A. Single palmar creases.
Choice A rationale: Single palmar creases (also known as simian creases) can be associated with certain genetic conditions, such as Down syndrome. The presence of this finding in a newborn should prompt further investigation and reporting to the healthcare provider for additional assessment and possible genetic testing.
Choice B rationale: Rust-stained urine in a newborn is typically caused by uric acid crystals, which are common and not considered abnormal during the first few days of life. This condition usually resolves without intervention, and it does not require reporting to the provider unless it persists or is accompanied by other symptoms.
Choice C rationale: Transient circumoral cyanosis is a common finding in newborns, especially when crying or feeding. It usually resolves on its own and is not considered an alarming sign unless it persists or is associated with central cyanosis or other signs of respiratory distress.
Choice D rationale: Subconjunctival hemorrhage is a common finding in newborns, usually resulting from the pressure changes during delivery. It typically resolves on its own within a few weeks and does not require reporting to the provider unless there are signs of other underlying conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Droplet precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). This is not the case with Clostridium difficile.
Choice B rationale:
Airborne precautions are used for diseases or germs that are spread through the air (examples: tuberculosis, measles, chickenpox). This is not the case with Clostridium difficile.
Choice C rationale:
A protective environment is a room designed to reduce the risk of infections from airborne, droplet, and contact transmissions. It’s typically for patients who have undergone stem cell transplants. This is not necessary for Clostridium difficile.
Choice D rationale:
Contact precautions are used for diseases or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds). Clostridium difficile is spread via contact, hence contact precautions are appropriate.
Correct Answer is D
Explanation
Choice A rationale:
Desiring privacy with the newborn is not specific to the taking-in phase.
Choice B rationale:
Taking charge of all mothering tasks is more indicative of the taking-hold phase.
Choice C rationale:
Putting personal needs aside is not specific to the taking-in phase.
Choice D rationale:
Reviewing the birth experience with others is characteristic of the taking-in phase.
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