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
Transient circumoral cyanosis
Single palmar creases
Subconjunctival hemorrhage
The Correct Answer is C
A. Rust-stained urine: This is a common finding in newborns and is due to urate crystals in the urine. It is benign and typically resolves as the infant's kidney function matures.
B. Transient circumoral cyanosis: This is a common finding in newborns, particularly during crying or feeding, and it usually resolves on its own. It does not typically indicate a serious condition.
C. A single palmar crease (also known as a simian crease) can be a normal variant, but it is often associated with certain congenital anomalies or chromosomal disorders, such as Down syndrome. The nurse should report this finding to the provider for further evaluation and possible genetic testing.
D. Subconjunctival hemorrhage: This can occur during delivery due to the pressure of vaginal birth. It is harmless and usually resolves within a few weeks without treatment.
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Related Questions
Correct Answer is B
Explanation
A. This option is incorrect because the development of breast tissue in newborns is not directly related to the mother’s hormone levels during pregnancy. Newborns typically have breast buds regardless of maternal hormone variations.
B. A flat areola with no breast bud is a characteristic finding in preterm newborns. Breast tissue development is one of the physical markers used to assess gestational age, and the lack of a breast bud is an indicator of immaturity, suggesting a preterm gestational age.
C. Ambiguous secondary sex characteristics are not related to the presence or absence of breast buds in newborns. This option focuses on sexual development rather than gestational markers.
D. A flat areola with no breast bud is a normal finding in preterm infants and does not indicate a congenital anomaly. This condition is expected in preterm newborns based on their developmental stage.
Correct Answer is B
Explanation
The client who is at 34 weeks of gestation and is experiencing epigastric pain and headache should be assessed first. These symptoms may indicate preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and organ damage. The nurse should monitor the client's blood pressure and assess for signs of organ damage, such as proteinuria, visual disturbances, and epigastric or right upper quadrant pain. The other clients may also require assessment and intervention, but their symptoms are less urgent and may indicate less serious conditions, such as a urinary tract infection (painful urination), early pregnancy symptoms (nausea and vomiting), or early labor (cramping and spotting).
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