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 C

The correct answer is Choice C.

Choice A rationale: Bluish discoloration of the hands and feet (acrocyanosis) is common in newborns and usually resolves within the first few days of life. It is not typically a priority unless it persists or is accompanied by other signs of distress.

Choice B rationale: Overlapping of the cranial bones (craniosynostosis) requires monitoring but is not an immediate priority unless there are signs of increased intracranial pressure.

Choice C rationale: Forward and lateral positioning of the ears can be indicative of certain genetic conditions, such as Down syndrome. This finding is significant as it can signal the need for further evaluation and intervention to address any associated health concerns.

Choice D rationale: Small, distended white sebaceous glands on the face (milia) are common in newborns and resolve on their own without intervention.

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Correct Answer is D

Explanation

Choice A rationale:

The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.

Choice B rationale:

Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.

Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.

Choice C rationale:

Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.

A. Request that the provider insert an intrauterine pressure catheter. B. Exert continuous upward pressure on the presenting part. C. Initiate oxytocin via continuous IV infusion. D. Place the client in the left-lateral position.

Correct Answer is B

Explanation

Choice A rationale:

Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.

Choice B rationale:

Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.

Choice C rationale:

Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.

Choice D rationale:

Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.

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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 providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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