A nurse is assessing a newborn who is 4 hr. old. Which of the following findings should the nurse identify as the priority to report to the provider?

Overlapping of the cranial bones

Small, distended white sebaceous glands on the face

Forward and lateral positioning of the ears

Bluish discoloration of the hands and feet

Answer and Explanation

The Correct Answer is D

In a newborn, bluish discoloration of the hands and feet may indicate a condition called peripheral cyanosis, which suggests poor oxygenation. It is important to report this finding to the healthcare provider promptly, as it may indicate a respiratory or circulatory problem that requires immediate attention.

Option a) Overlapping of the cranial bones is a common finding in newborns due to the molding of the head during delivery. This is not a priority finding to report unless there are other signs of concern, such as abnormal head shape or signs of trauma.

Option b) Small, distended white sebaceous glands on the face are called milia and are a normal finding in newborns. They are not a priority finding to report and typically resolve on their own within a few weeks.

Option c) Forward and lateral positioning of the ears is a normal finding in a newborn and is not a priority to report. The ears may appear folded or positioned diﬀerently due to the pressure and positioning in the womb.

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Correct Answer is A

Explanation

After a client with eclampsia experiences a convulsion, the nurse should immediately prioritize ensuring adequate oxygenation for the client. Administering oxygen via a face mask at 10 L/min helps to increase oxygen levels and support the client's respiratory function. This intervention addresses the immediate need for oxygenation and helps support the client's respiratory function following a convulsion associated with eclampsia. Prompt and appropriate management of eclampsia is crucial to ensure the safety and well-being of both the mother and the fetus.

Option b) Placing the client in a Trendelenburg position (head down and legs elevated) is not appropriate in this situation. It can potentially worsen blood ﬂow to the brain and may lead to increased intracranial pressure.

Option c) Assisting the client to void may be important for monitoring urine output, but it is not the immediate priority following a convulsion. The client's safety and stabilization take precedence.

Option d) Giving calcium gluconate is not indicated for the management of eclampsia. Calcium gluconate is used to treat hypocalcemia or as an antidote for certain medication toxicities. The primary treatment for eclampsia involves controlling and preventing seizures, which is not achieved through calcium gluconate administration.

A. Macrosomia B. Cataracts C. Hearing loss D. Urinary tract infection

Correct Answer is C

Explanation

Cytomegalovirus (CMV) is a common virus that belongs to the herpes family. Most people who get infected with CMV have no symptoms or only mild symptoms, such as fever, fatigue, or sore throat. However, CMV can cause serious problems in newborns who are infected before birth or around the time of birth. This is called congenital CMV infection¹.
Congenital CMV infection can aﬀect various organs and systems in the newborn, such as the brain, eyes, liver, spleen, lungs, and blood. Some of the possible signs and symptoms of congenital CMV infection are:
- Low birth weight
- Small head size (microcephaly)
- Enlarged liver and spleen (hepatosplenomegaly)
- Yellow skin and eyes (jaundice)
- Purple skin patches or bleeding spots (petechiae or purpura)
- Pneumonia
- Seizures
- Inﬂammation of the brain (encephalitis) or eye (retinitis)
One of the most common and serious complications of congenital CMV infection is hearing loss. Hearing loss can aﬀect one or both ears and can range from mild to profound. Hearing loss can be present at birth or develop later in childhood. Hearing loss can aﬀect the child's speech, language, and cognitive development².
Hearing loss due to congenital CMV infection is often progressive, meaning that it can worsen over time. Therefore, newborns who are diagnosed with congenital CMV infection should have regular hearing tests to monitor their hearing status and receive early intervention if needed. Early intervention may include hearing aids, cochlear implants, speech therapy, or sign language².

The other options are not typical signs of congenital CMV infection and have diﬀerent causes:
a) Macrosomia is a condition in which a newborn has a birth weight above the 90th percentile for their gestational age. It can be caused by maternal diabetes, obesity, genetics, or prolonged pregnancy.
b) Cataracts are cloudy areas in the lens of the eye that impair vision. They can be caused by genetic disorders, infections, trauma, or exposure to certain drugs or radiation.
d) Urinary tract infection is an infection of the bladder, urethra, kidneys, or ureters. It can be caused by
bacteria, viruses, fungi, or parasites.

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A nurse is assessing a newborn who is 4 hr. old. Which of the following findings should the nurse identify as the priority to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion?

Correct Answer is A

Explanation

A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?

Correct Answer is C

Explanation

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