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 A
Explanation
A. Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and self-inflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
B. Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
C. Histrionic personality disorder is characterized by excessive emotionality and attention-seeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
D. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
Correct Answer is A
Explanation
A. Irritability: Correct. Irritability is one of the signs of hypoglycemia, which occurs when blood glucose levels fall below 70 mg/dL (3.9 mmol/L). Other signs include shakiness, sweating, hunger, headache, confusion, and blurred vision.
B. Increased urination: Incorrect. Increased urination is one of the signs of hyperglycemia, which occurs when blood glucose levels rise above 180 mg/dL (10 mmol/L). Other signs include thirst, dry mouth, fatigue, nausea, and fruity breath odor.
C. Vomiting: Incorrect. Vomiting is not a specific sign of hypoglycemia or hyperglycemia, but it can occur as a complication of either condition if left untreated or poorly managed.
D.Facial flushing: Incorrect. Facial flushing is not a sign of hypoglycemia or hyperglycemia, but it can occur as a side effect of some medications used to treat diabetes, such as niacin or rosiglitazone.
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