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?

Bluish discoloration of the hands and feet.

Overlapping of the cranial bones.

Forward and lateral positioning of the ears.

Small, distended white sebaceous glands on the face.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Bluish discolouration of the hands and feet in a 4-hour-old newborn is likely due to peripheral cyanosis, which is common in the immediate postpartum period and usually resolves on its own without intervention. It is not the priority finding to report to the provider.

Choice B rationale:

This is the correct answer. Overlapping of the cranial bones in a newborn is a significant finding that should be reported to the provider promptly. It may indicate craniosynostosis, a condition in which the sutures of the skull close too early, potentially affecting brain growth.

Choice C rationale:

Forward and lateral positioning of the ears in a 4-hour-old newborn is a normal finding and does not require immediate reporting to the provider.

Choice D rationale:

Small, distended white sebaceous glands on the face, known as milia, are common in newborns and are not a priority finding to report to the provider. They are benign and usually resolve on their own without treatment.

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Correct Answer is C

Explanation

Choice A rationale:

The nurse should not advise the client to "Move your toddler to his new bed 2 months before the baby comes home.”. This can disrupt the toddler's routine and create unnecessary stress during a significant transition in their life.

Choice B rationale:

It is not appropriate to "Avoid bringing your toddler to prenatal visits.”. Involving the toddler in prenatal visits can help them adjust to the idea of a new sibling and reduce potential jealousy or feelings of being excluded.

Choice C rationale:

The correct answer is to "Let your toddler see you carrying the baby into the home for the first time.”. This approach allows the toddler to witness the arrival of the new sibling and can help them feel involved and excited about the new addition to the family.

Choice D rationale:

"Require scheduled interactions between the toddler and the baby”. is not the best response. While it's essential to facilitate interactions between the toddler and the baby, forcing scheduled interactions may cause stress and resistance, especially if the toddler is not ready for such encounters.

A. Increased fetal movement. B. Increased urinary output. C. Increased muscle weakness. D. Increased respiratory rate.

Correct Answer is C

Explanation

Choice A rationale:
Increased fetal movement is a positive sign during pregnancy and indicates the well-being of the baby. It is not a concern and does not require reporting.

Choice B rationale:
Increased urinary output may be expected in a client receiving magnesium sulfate due to its diuretic effects. This finding is not alarming and does not require immediate reporting unless it is associated with other concerning symptoms.

Choice C rationale:
Increased muscle weakness is a potential side effect of magnesium sulfate administration. It is important to monitor the client for signs of magnesium toxicity, and increased muscle weakness should be reported promptly as it may indicate the need for adjustments in the dosage or administration of the medication.

Choice D rationale:
Increased respiratory rate is not typically associated with magnesium sulfate use and is unlikely to be a concerning finding in this context. However, it's always essential to monitor respiratory status, but it may not be specifically related to the magnesium sulfate treatment.

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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

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