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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client is pacing around the chair in which their partner is sitting.
Rationale:
- A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
- B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
- C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
- D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.
Correct Answer is D
Explanation
Choice A rationale:
The statement, "I can expect my eyelids to be bruised after this procedure," indicates an understanding of the common side effects of cataract removal surgery. Bruising around the eyes is a common occurrence due to the manipulation of tissues during the procedure.
Choice B rationale:
The statement, "I will see dark spots in my vision after this procedure," is incorrect. Dark spots in vision are not a normal or expected outcome of cataract removal surgery. This statement shows a misunderstanding of the procedure.
Choice C rationale:
The statement, "I will receive general anesthesia for this procedure," is incorrect. While anesthesia is administered during the procedure, specifying the type of anesthesia is not crucial for the client's understanding of the surgery itself. The focus should be on the procedure details rather than the type of anesthesia.
Choice D rationale:
The statement, "I know the provider will replace the lens in my eyes during this procedure," indicates a clear understanding of the cataract removal procedure. The main goal of cataract surgery is to remove the cloudy lens and replace it with a clear artificial lens, improving the patient's vision. This statement demonstrates the client's comprehension of the surgery process.
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