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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A is incorrect because documenting client tasks upon completion is an appropriate action by the newly licensed nurse that demonstrates accuracy and timeliness of documentation.
B is correct because starting a task then determining what supplies are needed is an inappropriate action by the newly licensed nurse that indicates poor planning and organization skills.
C is incorrect because completing a client assessment while infusing an IV antibiotic over 30 min is an appropriate action by the newly licensed nurse that demonstrates efficient use of time and multitasking ability.
D is incorrect because returning to the nurses' station after completing several tasks in the same location is an appropriate action by the newly licensed nurse that demonstrates effective prioritization and delegation skills.
Correct Answer is D
Explanation
A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.
B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.
C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.
D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate life-saving interventions.
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