A nurse is caring for a newborn 8 hours of age.Which of the following assessment findings require follow-up by the nurse?
Large ecchymotic caput succedaneum noted on posterior scalp.
Yellow discoloration noted of sclera and oral mucosa.
Fontanel level and soft.
Respiratory rate 78/min.
Correct Answer : A,B,D
Choice A rationale
A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.
Choice B rationale
Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.
Choice C rationale
A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.
Choice D rationale
A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.2"]
Explanation
Step 1 is 3000 grams ÷ 1000 = 3 kg.
Step 2 is 3 kg × 24 mg = 72 mg.
Step 3 is 72 mg ÷ (50 mg ÷ 5 ml) = 1.2 ml.
Answer: 1.2 ml.
Correct Answer is A
Explanation
Choice A rationale: Oxytocin is the hormone responsible for the let-down reflex during breastfeeding. It is released from the posterior pituitary gland in response to the baby’s suckling. This hormone causes the milk ducts to contract and eject milk from the alveoli into the ducts, making it available for the baby.
Choice B rationale: Progesterone plays a role in preparing the breast tissue for lactation during pregnancy, but it does not directly trigger the let-down reflex.
Choice C rationale: Hindmilk is the milk produced later in a feeding session, which is richer in fat and calories. It is not a hormone and does not cause the let-down reflex.
Choice D rationale: Foremilk is the initial milk released during breastfeeding, which is higher in water content. It is also not a hormone and does not cause the let-down reflex.
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