A nurse is assessing a newborn following a vaginal birth. Which of the following findings should the nurse identify as requiring follow-up? (Select All that Apply.)

Presence of a two-vessel umbilical cord

Molding of the skull

Asymmetry of ears

Tongue extending past the lower

Diminished breath sounds on one side

Answer and Explanation

Correct Answer : A,C,E

A) Presence of a two-vessel umbilical cord:
The presence of a two-vessel umbilical cord (instead of the normal three vessels, which includes two arteries and one vein) is a significant finding that requires follow-up. A two-vessel cord can be associated with fetal anomalies, particularly with renal, cardiac, or chromosomal conditions. Therefore, it requires further evaluation to rule out any underlying conditions and ensure proper organ development.

B) Molding of the skull:
Molding of the skull is a normal and expected finding in newborns following a vaginal birth, especially after a long or difficult delivery. It refers to the temporary reshaping of the fetal skull bones as they overlap to pass through the birth canal. This is typically self-correcting and resolves within a few days, so no follow-up is needed for molding.

C) Asymmetry of ears:
Asymmetry of the ears can indicate congenital anomalies, such as craniofacial syndromes or other physical deformities. Although some degree of asymmetry can occur in newborns, especially in the first hours of life, persistent or significant asymmetry should be evaluated further. It may indicate an abnormality that requires follow-up or assessment by a specialist.

D) Tongue extending past the lower lip:
A tongue that extends past the lower lip is a normal finding in newborns, as babies are still developing their oral reflexes and muscle tone. This is not a cause for concern, and no follow-up is required unless other feeding issues arise. It's important to differentiate between normal tongue movements and more serious concerns like tongue-tie (ankyloglossia), but this is not indicative of a problem by itself.

E) Diminished breath sounds on one side:
Diminished breath sounds on one side of the chest can indicate a serious issue, such as a pneumothorax, diaphragmatic hernia, or other respiratory concerns. This finding warrants immediate follow-up, as the newborn could be experiencing a respiratory distress condition that needs urgent intervention and management. This is a significant finding requiring immediate evaluation.

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Correct Answer is ["5"]

Explanation

Given:

Desired dose: Digoxin 0.25 mg PO daily

Available concentration: Digoxin 500 mcg/10 mL

To find:

Volume to administer (in mL)

Step 1: Convert desired dose to micrograms

We know that 1 milligram (mg) is equal to 1000 micrograms (mcg). Therefore, to convert the desired dose from mg to mcg, we multiply by 1000:

Desired dose (mcg) = Desired dose (mg)x 1000

Desired dose (mcg) = 0.25 mg x 1000 = 250 mcg

Step 2: Set up the proportion

We can use the following proportion to solve the problem:

(Desired dose) / (Available concentration) = Volume to administer

Step 3: Substitute the values

Plugging in the given values, we get:

(250 mcg) / (500 mcg/10 mL) = Volume to administer

Step 4: Simplify

To simplify, we can invert the denominator and multiply:

(250 mcg) x (10 mL / 500 mcg) = Volume to administer

The "mcg" units cancel out, leaving us with:

(250 x 10 mL) / 500 = Volume to administer

Step 5: Calculate

Performing the multiplication and division, we get:

2500/ 500 = Volume to administer

5 mL = Volume to administer

A. Category I B. Category Il C. Uncategorized D. Category III

Correct Answer is B

Explanation

A) Category I:
Category I fetal heart rate patterns are considered normal and are characterized by a baseline fetal heart rate of 110–160 beats per minute, moderate variability, and the presence of accelerations. The pattern also lacks concerning decelerations. While this client’s fetal heart rate is within the normal baseline range (150 bpm), the presence of occasional variable decelerations indicates that the fetal heart rate pattern does not meet the criteria for Category I.

B) Category II:
Category II includes all fetal heart rate patterns that are not classified as Category I or III. This category represents indeterminate or concerning patterns, which require ongoing assessment and interventions. In this case, the fetal heart rate pattern includes a baseline within the normal range, moderate variability, accelerations, but also occasional variable decelerations. Variable decelerations, particularly when they occur intermittently, are often considered non-reassuring but not immediately concerning if they resolve quickly, placing the pattern in Category II.

C) Uncategorized:
"Uncategorized" refers to situations where the fetal heart rate pattern cannot be classified due to insufficient information or an unclear pattern. This is not applicable here because the nurse has identified sufficient data to classify the pattern.

D) Category III:
Category III patterns are considered abnormal and require prompt intervention. These patterns are characterized by persistent decelerations, such as late decelerations, bradycardia, or variable decelerations that do not resolve with interventions. Since the variable decelerations in this case are occasional and not persistent or severe, this pattern does not meet the criteria for Category III.

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A nurse is assessing a newborn following a vaginal birth. Which of the following findings should the nurse identify as requiring follow-up? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is ordered digoxin 0.25mg po. daily. On hand is a liquid in a dropper bottle labeled 500mcg/10mL. How many milliliters will be administered?

Correct Answer is ["5"]

Explanation

Correct Answer is B

Explanation

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