A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

Heart rate 136/min

Nasal flaring

Transient strabismus

Overlapping of sutures

Answer and Explanation

The Correct Answer is B

A. Heart rate 136/min is a normal finding for a newborn. The normal range of heart rate for a newborn is 100 to 160/min.

B. Nasal flaring is an abnormal finding for a newborn. Nasal flaring indicates respiratory distress and may be caused by conditions such as pneumonia, meconium aspiration, or congenital heart defects.

C. Transient strabismus is a normal finding for a newborn. Transient strabismus is a temporary misalignment of the eyes that occurs due to weak eye muscles and poor coordination. It usually resolves by 3 to 6 months of age.

D. Overlapping of sutures is a normal finding for a newborn. Overlapping of sutures is caused by molding of the skull during delivery and allows the head to fit through the birth canal. It usually resolves within a few days after birth.

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Correct Answer is D

Explanation

Choice A reason:

Face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.

Choice B reason

Shoulders is incorrect: The shoulders are not typically indicative of jaundice.

Choice C reason:

Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.

Choice D reason:

Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.

A. Select a 1-inch needle. B. Use a 45° angle when inserting the needle. C. Use the ventrogluteal site. D. Pinch the skin up during injection.

Correct Answer is C

Explanation

A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.

B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.

C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.

D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

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A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

Correct Answer is D

Explanation

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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