A nurse is assessing a newborn on the first day of life. Which of the following is an expected finding? (Select All that Apply.)
Fusion of labia in female genitalia
Erythema toxicum on newborn's skin
Hypospadias is noted in the male newborn
Presence of syndactyly in extremities
Negative Ortolani sign
Correct Answer : B,E
A) Fusion of labia in female genitalia:
Fusion of the labia in a female newborn is not an expected finding. This could indicate a condition such as labial adhesion or an abnormality in the development of the genitalia. Normally, the labia in a female newborn are separated. Any signs of fusion would require further evaluation by the healthcare provider.
B) Erythema toxicum on newborn's skin:
Erythema toxicum is a common and expected finding in newborns, usually appearing within the first 2–3 days of life. It consists of small, red papules or pustules on a red base, often described as a "flea-bitten" appearance. This rash is benign and resolves on its own within a few days to weeks. It is not associated with any infection or underlying health issues.
C) Hypospadias is noted in the male newborn:
Hypospadias, a condition where the urethral opening is located on the underside of the penis rather than at the tip, is not an expected finding in all newborn males. While it occurs in a small percentage of male infants, it is a congenital anomaly that would require further assessment and possibly surgical correction. It is not considered a normal finding in a newborn.
D) Presence of syndactyly in extremities:
Syndactyly, the condition where two or more fingers or toes are fused together, is not a normal finding in newborns. While it is a congenital anomaly that can occur in some infants, it is not expected and requires further evaluation and possibly surgical intervention depending on the severity.
E) Negative Ortolani sign:
A negative Ortolani sign is an expected and normal finding in a newborn. The Ortolani maneuver is used to assess for hip dislocation, and a negative result indicates that the hip is stable and not dislocated. If the Ortolani sign were positive, it would suggest the presence of a developmental hip dysplasia, which would require further diagnostic evaluation. A negative sign is considered typical and reassuring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Goodell’s sign:
Goodell's sign refers to the softening of the cervix that occurs early in pregnancy, typically around 4–6 weeks. It is a probable sign of pregnancy due to increased vascularity and hormonal changes. However, it does not describe the movement of the fetus or the sensation felt by the provider when pressure is applied to the cervix.
B) Lightening:
Lightening refers to the sensation of the fetus dropping or descending into the pelvic cavity, which typically happens in the later stages of pregnancy (around 36 weeks or later). It is not related to the fetal movement felt by the provider through upward pressure on the cervix, but rather to the physical repositioning of the fetus as it prepares for labor.
C) Ballottement:
Ballottement is the correct term for the movement of the fetus that can be felt by the provider when upward pressure is applied to the cervix. This technique involves a gentle tapping or pushing on the cervix, causing the fetus to rise and then "bounce" back. This is a probable sign of pregnancy, typically noticeable between 16 and 18 weeks gestation.
D) Chadwick's sign:
Chadwick’s sign refers to the bluish discoloration of the cervix, vagina, and vulva due to increased blood flow and is often an early sign of pregnancy. It does not relate to the movement of the fetus felt by the provider, but rather to changes in the color of the genital tissues.
Correct Answer is ["D","E","I","K"]
Explanation
The newborn's assessment findings that require follow-up:
Temperature 35.7°C (96.3°F) at 2200:
Hypothermia in newborns can lead to cold stress, which increases the risk of respiratory distress and hypoglycemia. The newborn’s temperature should be closely monitored, and warming measures should be initiated to prevent further complications.
Respiratory rate 68/min at 2200:
A respiratory rate above 60 breaths per minute in a newborn is considered tachypnea and can indicate respiratory distress or underlying conditions such as infection. The newborn should be further evaluated to determine the cause of the tachypnea and to ensure proper oxygenation.
Sternal retractions at 2200:
Sternal retractions suggest that the newborn is experiencing increased work of breathing, which is a key sign of respiratory distress. This requires immediate evaluation to assess the severity and identify potential causes, such as respiratory infections or inadequate ventilation.
Coarse rhonchi in bilateral lung fields at 2200:
The presence of coarse rhonchi indicates abnormal breath sounds, often related to fluid retention or infection in the lungs. This finding requires further assessment and possibly interventions to clear the airway and support respiratory function.
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