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 B

Explanation

Choice A rationale:

A client with placenta previa and a hematocrit of 36% should be monitored closely due to the risk of bleeding, but it is not an immediate priority compared to the client with hyperemesis gravidarum and a low sodium level.

Choice B rationale:

Hyperemesis gravidarum is a severe form of morning sickness characterized by excessive vomiting, leading to dehydration and electrolyte imbalances. A sodium level of 110 mEq/L is dangerously low and requires immediate attention to correct the electrolyte disturbance and prevent further complications.

Choice C rationale:

A client with diabetes mellitus and an HbA1c of 5.8% is within a normal range, indicating good glycemic control. This client's condition can be managed on an outpatient basis and does not require urgent assessment compared to the others.

Choice D rationale:

A client with preeclampsia and a creatinine level of 1.1 mg/dL should be closely monitored, but it is not the priority over the client with hyperemesis gravidarum and severe electrolyte imbalance.

A. The mother and the father are both Rh positive. B. The mother is Rh positive and the father is Rh negative. C. The mother is Rh negative and the father is Rh positive. D. The mother and the father are both Rh negative.

Correct Answer is C

Explanation

Choice A rationale:

If both the mother and the father are Rh positive, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

Choice B rationale:

When the mother is Rh positive and the father is Rh negative, there is no risk of hemolytic disease in the newborn. Hemolytic disease results from Rh incompatibility, which occurs when the mother is Rh negative, and the father is Rh positive.

Choice C rationale:

This is the correct answer. Hemolytic disease of the newborn occurs when the mother is Rh negative, and the father is Rh positive. In such cases, the baby may inherit the Rh factor from the father, leading to Rh incompatibility between the mother and the baby's blood, potentially causing hemolytic disease.

Choice D rationale:

If both the mother and the father are Rh negative, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

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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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Correct Answer is B

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Correct Answer is C

Explanation

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